Download Prehospital Emergency Pharmacology

Medications and Pharmacology
May 2012 CME
By Silver Cross EMS Staff
(with help from Pearson Education)
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Our agenda
• A review of basic pharmacology.
• A review of some ALS and BLS medications in
Region 7.
• A review of medication use in certain medical
and trauma situations.
• A review of medical math (ugh!)
• (ALS only) EKG strip o’ the month: ectopic
beats
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Sources
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Research and Bringing a Drug to
Market
• The pharmaceutical industry is highly motivated
to bring profitable new drugs to market.
• Proving safety and reliability of these new drugs
requires extensive research.
• Drugs can become “generic” when original
company’s patent expires.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Schedule
of
Controlled
Drugs
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Names
 Chemical names
 Generic names
 Trade names
 Official names
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Names (cont.)
• Chemical name
– A precise description of a drug’s chemical
composition and molecular structure.
• ethyl 1-methyl-4phenylisonipectorate
hydrochloride
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Names (cont.)
Generic name
A markedly abbreviated form of the chemical
name of the drug.
Generic medications usually have the same
therapeutic efficacy as the nongeneric and are
generally less expensive.
meperidine hydrochloride
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Names (cont.)
• Trade name
– A copyrighted name designated by the drug
company that sells the medication.
– Trade names are proper nouns.
• The first letter is capitalized.
• Demerol® hydrochloride
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Names (cont.)
Official name
Followed by the initials USP or NF, denoting a
listing in one of the official publications.
Usually the same as the generic name.
meperidine hydrochloride, USP
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Forms
 Liquid forms
 Solid drugs
 Suppositories
 Inhalants
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Forms (cont.)
 Liquid forms
 Solutions
 Tinctures
 Suspensions
 Spirits
 Emulsions
 Elixirs
 Syrups
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Forms (cont.)
 Solid drugs
 Pills
 Powders
 Capsules
 Tablets
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Forms (cont.)
 Suppositories
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Drug Forms (cont.)
 Inhalers
 Metered-dose
 Small-volume
nebulizer
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Ampules
 Single dose
 Not frequently used in
EMS
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Prefilled Syringes
• Easy to use
• Packaged in common
doses
• Usually color-coded
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Tubex Syringes
 Often used for
controlled substances
 Require Tubex
adaptor
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Vials
 Dosage and volume
vary by drug and
manufacturer
 Often less expensive
than other
preparations
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Single-Dose Vials
 Common in
emergency medicine
 Usually contain
standard dose (but
can vary by
manufacturer)
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Important Pharmacological Terminology
 Antagonism
 Opposition between two or more medications.
 Bolus
 Single, often large dose of medication.
 Contraindications
 Medical or physiological conditions present in a
patient that would make it harmful to administer a
medication of otherwise known therapeutic value.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Important Pharmacological Terminology
(cont.)
 Cumulative action
 Occurs when a drug is administered in several doses,
causing an increased effect. This increased effect is
usually due to a quantitative buildup of the drug in the
blood.
 Depressant
 Medication that decreases or lessens a body function
or activity.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Important Pharmacological Terminology
(cont.)
 Habituation
 Physical or psychological dependence on a drug.
 Hypersensitivity
 A reaction to a substance that is normally more
profound than seen in a population not sensitive to
the substance.
 Idiosyncrasy
 An individual reaction to a drug that is usually
different from that seen in the rest of the
population.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Important Pharmacological Terminology
(cont.)
 Indication
 A medical condition or conditions in which a drug
has proven to be of therapeutic value.
• Potentiation
– Enhancement of one drug’s effect by another.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Important Pharmacological Terminology
(cont.)
 Refractory
 Patients or conditions that do not respond to a
drug are said to be refractory to the drug.
 Side effects
 Unavoidable, undesired effects frequently seen
even in therapeutic drug dosages.
 Stimulant
 A drug that enhances or increases a bodily
function.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Important Pharmacological Terminology
(cont.)
 Synergism
 The combined action of two drugs. The action is much
stronger than the effects of either drug administered
separately.
 Therapeutic action
 The desired, intended action of a drug given in the
appropriate medical condition.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Important Pharmacological Terminology
(cont.)
 Tolerance
 When patients are receiving drugs on a long-term
basis, they may require larger and larger dosages of
the drug to achieve a therapeutic effect.
 Untoward effect
 A side effect that proves harmful to the patient.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
• The study of drug concentrations in body
fluids and tissues, and the variables that
influence how the concentrations vary with
time.
– Absorption
– Distribution
– Metabolism (biotransformation)
– Elimination
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Review of Physiology of
Transport
Drug absorption
Solubility of the drug
Concentration of the drug
pH of the drug
Site of absorption
Absorbing surface area
Blood supply to the site of absorption
Bioavailability
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Review of Physiology of Transport
(cont.)
Distribution
Cardiovascular function
Regional blood flow
Drug storage reservoirs
Physiological barriers
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Comparison of Drug Levels Following IM
and SC Injections
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Comparison of Rates of Drug Absorption of
Various Routes of Administration
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Comparison of Drug Levels Following IV and
Oral Drug Administration
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacodynamics
Effects of drugs on the body, and
biochemical and physiological
mechanisms of drug actions.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Epinephrine Interacting with Beta Receptor
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
β Receptor Blocked by Propranolol
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacodynamics (cont.)
Therapeutic index: the difference between
the minimum effective concentration and
the toxic level.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Comparison of Blood Levels Following Subtherapeutic,
Therapeutic, and Toxic Doses of the Same Drug
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacodynamics
Special considerations in drug therapy
Pediatric patients
Broselow Tape
Geriatric patients
Pregnancy and lactation
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
A Broselow Tape is useful for calculating
drug dosages for pediatric patients.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
The Medication Order
Medication desired
Dose desired
Administration route
Administration rate
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Enteral Routes
Oral (PO)
Orogastric/nasogastric (OG/NG)
Sublingual (SL)
Buccal
Rectal (PR)
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Parenteral Routes
 Topical
 Intradermal
 Intranasal
 Subcutaneous (SC)
 Intramuscular (IM)
 Intravenous (IV)
 Endotracheal (ET)
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
 Sublingual injection
 Intracardiac (IC)
 Intraosseous
 Inhalational
 Umbilical
 Vaginal
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Body Substance Isolation (BSI)
 Always take BSI measures appropriate for the
risk.
 Hand-washing is important, yet often
neglected.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Disposal of Contaminated Equipment
and Sharps
Minimize the tasks you perform in a
moving vehicle
Immediately dispose of used sharps in a
sharps container
Recap needles ONLY as a last resort
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Medication Routes Used in Emergency
Medicine
Administration of medication
Identify patient allergies prior to base hospital
contact
Take and record vital signs
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Medication Routes Used in Emergency
Medicine (cont.)
Administration of medication
Determine if the order is consistent with
training and scope of practice
Confirm the order by repeating:
Medication
Dosage, volume, and concentration
Route of administration
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Medication Routes Used in Emergency
Medicine (cont.)
Administration of medication
Write down the order and time of order
Select the proper medication and check the
name of the medication:
When the medication is first selected
When drawing up the medication
When replacing medication in storage or disposing
of ampule
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Medication Routes Used in Emergency
Medicine (cont.)
Administration of medication
Check for cloudiness, particles, discoloration,
and expiration date
Confirm order and medication with partner
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Medication Routes Used in Emergency
Medicine (cont.)
Administration of medication
Prior to administration of any medication,
check the six rights:
RIGHT patient
RIGHT medication
RIGHT dose
RIGHT route
RIGHT time
RIGHT documentation
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Medication Routes Used in Emergency
Medicine (cont.)
• Administration of medication
– Record
•
•
•
•
Drug dose and volume
Route
Time
Check and record patient’s V/S
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Medical Math
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Why medical math? Oh why?
• Many drugs on shortages these days.
• We are getting different concentrations into
the pharmacy
• Easy to screw up dosages when dealing with
an unfamiliar drug or concentration.
• We are even testing system entry candidates
on medical math now!
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Easy as pie (The food, not Pi)
• First, always carry a cheap calculator in the
ambulance (1 buck at Big Lots).
• Then, just remember this simple formula:
VxD
C
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Huh?
VxD
C
• V is volume (usually ml)
• D is dose (how much is ordered)
• C is concentration (you have/on hand)
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
So for example
• You have 5mg/1ml of Versed. Medical control orders
10mg. How many ml would you give?
• V=1ml
• D=10mg
• C=5mg/ml
1ml x 10mg = 10 = 2ml Versed
5mg
5
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Another example
• You have 100mg/10ml of Lasix. Medical control
orders 75 mg. How many ml would you give?
• V=10ml
• D=75mg
• C=100mg
• 10ml x 75mg = 75ml = 7.5 ml Lasix
• 100mg
10
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Conversions are also important
• The dose of drug A is 1mg/kg for a patient weighing 198
pounds. How many mg would you give?
• First convert 198 pounds to kg.
• 1kg = 2.2 pounds
• So patient weighs 90kg
• You could “ballpark” it by dividing the pounds by 2, but
do you want your critically ill family member ballparked
in an ambulance? We didn’t think so….
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Then figure the dose
• The dose of drug A is 1mg/kg for a patient weighing 198
pounds. How many mg would you give?
• 1mg x 90 = 90mg of drug A
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Oxygen
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
Class: gas
Oxygen is an odorless, tasteless, colorless gas
necessary for life.
Mechanism of action: Oxygen is transported
to the cells by hemoglobin.
Oxygen is required for the efficient breakdown
of glucose into a usable energy form.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
Immediate
Peak effects
< 1 minute
Duration
< 2 minutes
Half-life
N/A
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications and Contraindications
Whenever hypoxia is suspected or possible
In any critical patient
There are no real contraindications to oxygen.
Some studies suggest limiting oxygen but not
conclusive… yet.
Hypoxic patients should never be deprived of
oxygen for fear of respiratory depression.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
• Use cautiously in patients with chronic obstructive
pulmonary disease (COPD) on longer transports.
• Monitor for respiratory depression if high
concentrations of oxygen are delivered.
• High concentrations of oxygen to neonates can
damage the infant’s eyes (retrolental fibroplasia).
– Rarely a problem in prehospital care, but is a consideration
in long-distance and prolonged transport.
• Flow rates of 6 Lpm or greater should be humidified.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Prolonged administration of high-flow,
nonhumidified oxygen may cause drying of
the mucous membranes.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Interactions
There are no interactions associated with
oxygen administration.
Oxygen may increase the toxicity of certain
herbicides that are sometimes sprayed on
illicit agricultural products such as marijuana.
Poisoning by these agents is uncommon.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Sympathomimetics
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Comparison of Sympathetic and
Parasympathetic Actions
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Effects of Alpha and Beta Adrenergic
Receptor Activity on Selected Organs
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
List of Sympathomimetic Drugs with
Adrenergic Actions
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Epinephrine
Sympathetic agonist
Epinephrine is a naturally occurring
catecholamine.
It is a potent α- and β-adrenergic stimulant;
however, its effect on β-receptors is more
profound.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
• Epinephrine acts directly on α- and β-adrenergic
receptors. Its effect on β-receptors is much more
profound, and includes the following:
–
–
–
–
–
–
Increased heart rate
Increased cardiac contractile force
Increased electrical activity in the myocardium
Increased systemic vascular resistance
Increased blood pressure
Increased automaticity
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
< 2 minutes (IV/ET)
Peak effects
< 5 minutes (IV/ET)
Duration
5-10 minutes (IV/ET)
Half-life
5 minutes
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications
Cardiac arrest
Asystole
Ventricular fibrillation
Pulseless ventricular tachycardia
PEA (pulseless electrical activity)
Severe anaphylaxis
Severe reactive airway disease
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Contraindications
Epinephrine 1:10,000 is contraindicated in
patients who do not require extensive
cardiopulmonary resuscitative efforts.
With simple allergic reactions and asthma, the
1:1000 dilution should be used and
administered subcutaneously.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
Should be protected from light
Can be deactivated by alkaline solutions such
as sodium bicarbonate
The IV line must be adequately flushed
between administrations of epinephrine and
sodium bicarbonate.
The effects of epinephrine can be intensified
in patients who are taking antidepressants.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Palpitations
Anxiety
Tremulousness
Headache
Dizziness
Nausea
Vomiting
Increased myocardial oxygen demand
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
• Cardiac arrest (adult)
– 1 mg of 1:10,000 IV/IO every 3-5 minutes
• Cardiac arrest (pediatrics)
– First dose – 0.01 mg/kg of 1:10,000 IV/IO
– Repeat every 3-5 minutes
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage (cont.)
Severe anaphylaxis (adult)
0.3-0.5 mg of 1:1,000 SQ
Repeat every 5-15 minutes
Severe anaphylaxis (pediatrics)
Initially 0.01 mg/kg of 1:1,000 IM
Max dose 0.3mg
In severe respiratory compromise
1:10,000 IV/IO, dose based on Broslow/peds tape
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dopamine HC1
Intropin
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
• Sympathetic agonist
• Dopamine is a naturally occurring
catecholamine.
• It acts on α, β1, and dopaminergic adrenergic
receptors.
• Its effect on α-receptors is dose-dependent.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
• Chemically related to both epinephrine and
norepinephrine and increases blood pressure
by acting on both α- and β1-adrenergic
receptors
• Causes a positive inotropic effect on the heart
• Does not increase myocardial O2 demand
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action (cont.)
• Does not have chronotropic effects
• Also acts on α-adrenergic receptors, causing
peripheral vasoconstriction
• When used in therapeutic dosages, maintains
renal and mesenteric blood flow
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action (cont.)
Dopamine increases both the systolic blood
pressure and the pulse pressure (the
difference between the systolic and diastolic
blood pressures), but, as a rule, there is
usually less effect on the diastolic pressure.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
 < 5 minutes
Peak effects
5-8 minutes
Duration
 < 10 minutes
Half-life
2 minutes
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications
Hemodynamically significant hypotension
(systolic blood pressure of 70 to 100 mmHg)
Not resulting from hypovolemia
Cardiogenic shock
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Contraindications
Should not be used as the sole agent in the
management of hypovolemic shock unless
fluid resuscitation is well under way
Should not be used in patients with known
pheochromocytoma (a tumor of the adrenal
gland)
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
• Can induce or worsen supraventricular and
ventricular dysrhythmias
• Whenever the dosage of dopamine surpasses
20 µg/kg/min, it functions very much like
norepinephrine.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Nervousness
Headache
Dysrhythmias
Palpitations
Chest pain
Dyspnea
Nausea and vomiting
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Interactions
Can be deactivated by alkaline solutions such
as sodium bicarbonate
Reduce doses if the patient is taking MAOIs
May cause hypotension when used
concomitantly with phenytoin (Dilantin)
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
• 800 mg diluted in 500 mL of D5W or 400 mg
diluted in 250 mL of D5W
• Concentration of 1600 µg/mL
• Initial infusion 2–5 µg/kg/min
• Titrate to blood pressure or until a maximum
of 20 µg/kg/min
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage (cont.)
 The effects of dopamine are dose dependent.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Antidysrhythmics
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Antidysrhythmics (cont.)
• Useful in the treatment and prevention of
cardiac dysrhythmias
• Some are useful in the treatment of atrial
dysrhythmias.
• Others are useful in the treatment of
ventricular dysrhythmias.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Lidocaine
Xylocaine
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
Class: Antidysrhythmic
An amide-type local anesthetic
Frequently used to treat life-threatening
ventricular dysrhythmias
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
Most frequently used antidysrhythmic agent
Suppresses depolarization and automaticity in
the ventricles
In therapeutic doses does not slow AV
conduction and does not depress myocardial
contractility
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
< 3 minutes
Peak effects
5-7 minutes
Duration
10-20 minutes
Half-life
1.5-2.0 hours
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications
Ventricular tachycardia
Ventricular fibrillation
Acute myocardial infarction
Electrical defibrillation
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications (cont.)
• Malignant PVCs
– More than six unifocal PVCs per minute
– Multifocal PVCs
– PVCs that occur in couplets
– Runs of more than two PVCs
– R on T phenomena
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Contraindications
Second-degree Mobitz II and third-degree
blocks
Whenever PVCs occur in conjunction with
bradycardia (heart rate less than 60 beats per
minute), the bradycardia should be treated
first.
If PVCs are still present after increasing the
rate, lidocaine should be administered.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
Central nervous system depression may occur
when the dosage exceeds 300 mg/hr.
Exceedingly high doses can result in coma and
death.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Drowsiness
Seizures
Confusion
Hypotension
Bradycardia
Heart blocks
Nausea and vomiting
Respiratory and cardiac arrest
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Interactions
• Should be used with caution when
administered concomitantly with
procainamide, phenytoin, quinidine, and βblockers because drug toxicity may result
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
Refractory V-fib and pulseless V-tach
1.0 to 1.5 mg/kg IV bolus
Repeat every 3-5 minutes at 0.5 to 0.75 mg/kg
Maximum bolus of 3.0 mg/kg
With ROSC, use IV infusion therapy
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage (cont.)
V-tach with a pulse and/or PVCs
1.0 to 1.5 mg/kg IV bolus
Repeat every 5-10 minutes at 0.5 to 0.75 mg/kg
Maximum bolus of 3.0 mg/kg
Maintenance drip of 2-4 mg/min
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Adenosine
Adenocard
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
Class: antidysrhythmic
A naturally occurring nucleoside that slows AV
conduction through the AV node
Has an exceptionally short half-life
Has a relatively good safety profile
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
A naturally occurring substance present in all
body cells
Decreases conduction of the electrical impulse
through the AV node and interrupts AV reentry pathways in PSVT
Can effectively terminate rapid
supraventricular arrhythmias
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action (cont.)
Half-life is approximately 10 seconds
Sometimes referred to as chemical
cardioversion
Effective in 90% of case studies
Does not appear to cause hypotension to the
same degree as does verapamil
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
20-30 seconds
Peak effects
20-30 seconds
Duration
30 seconds
Half-life
10 seconds
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications/Contraindications
Used in PSVT (including that associated with
Wolff-Parkinson-White syndrome) refractory
to common vagal maneuvers
Do not use in second heart block
Or third heart block
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
Typically causes dysrhythmias at the time of
cardioversion
In extreme cases, transient asystole may
occur.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Flushing
Headache
Shortness of breath
Dizziness
Nausea
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
Initial dose is 6 mg rapid IVP over 1-2 sec.
Follow the initial dose with a rapid saline
flush.
Two repeat doses of 12 mg rapid IVP may be
administered.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Magnesium Sulfate
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
Class: Antidysrhythmic
A salt that dissociates into the magnesium
cation (Mg2+) and the sulfate anion when
administered
An essential element in numerous
biochemical reactions that occur within the
body
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
• Acts as a physiological calcium channel blocker
and blocks neuromuscular transmission
• Appears to reduce the incidence of ventricular
dysrhythmias and other side effects following
an acute myocardial infarction
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
Immediate (IV), 1 hour (IM)
Peak effects
Variable
Duration
1 hour
Half-life
N/A
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications
For prolonged transport of pre-eclamptic or
toxemic pregnancy (4gm IV with medical
control approval).
May also be ordered by medical control for
Torsade de pointes (multiaxial ventricular
tachycardia)
Other regions may also use for asthma or full
arrests.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Contraindications
Patients in shock
Persistent severe hypertension
Third-degree AV block
Patients who routinely undergo dialysis
Hypocalcemia
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
Should be administered slowly to minimize
side effects
Should have continuous cardiac monitoring
Use with caution in patients with known renal
insufficiency
Calcium salts should be available as an
antidote in case serious side effects occur.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
 Flushing
 Sweating
 Bradycardia
 Decreased deep tendon reflexes
 Drowsiness
 Respiratory depression
 Dysrhythmias
 Hypotension
 Hypothermia
 Itching and rash
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Parasympatholytics
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Parasympatholytics
Drugs that inhibit the actions of the
parasympathetic nervous system
Sometimes referred to as anticholinergics
Primary nerve of the parasympathetic nervous
system is the vagus nerve
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Atropine Sulfate
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
Class: Anticholinergic
Parasympatholytic (anticholinergic) that is
derived from parts of the Atropa belladonna
plant
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
Potent parasympatholytic
Acts by blocking acetylcholine receptors, thus
inhibiting parasympathetic stimulation
Although has positive chronotropic properties,
has little or no inotropic effect
Mechanism by which atropine is effective in
asystole is not clear
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
Immediate
Peak effects
2-4 minutes
Duration
4 hours
Half-life
2-3 hours
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications
Hemodynamically significant bradycardia
Organophosphate poisonings
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Contraindications
No longer used in asystole, PEA
May not work well in pediatric patients whose
vagus nerve is not yet well-developed
May also not work in heart transplant patients
whose vagus nerve has been
damaged/severed.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
May actually worsen the bradycardia
associated with second-degree Mobitz II and
third-degree AV blocks
Maximum dose should not be exceeded
except in the setting of organophosphate
poisoning
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Blurred vision
Dilated pupils
Dry mouth
Tachycardia
Drowsiness
Confusion
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
Hemodynamically significant bradycardia
0.5 mg IVP every 3-5 minutes
Maximum of 0.04 mg/kg
Do not delay pacing in order to give Atropine
Pesticides/nerve agents
Adults 2mg IP every 5 minutes until secretions
diminished
Peds 0.02mg/kg
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Aspirin
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
Platelet aggregator inhibitor
Anti-inflammatory agent
An anti-inflammatory agent and an inhibitor
of platelet function
A useful agent in the treatment of various
thromboembolic diseases such as acute
myocardial infarction
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
• Blocks the formation of the substance
thromboxane A2
• Causes platelets to aggregate and arteries to
constrict
• Appears to reduce the rate of nonfatal
reinfarction and nonfatal stroke
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
5-30 minutes
Peak effects
15-120 minutes
Duration
1-4 hours
Half-life
15-20 minutes
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications
New chest pain suggestive of acute coronary
syndrome
Signs and symptoms suggestive of recent
stroke
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications/Contraindications
New chest pain suggestive of acute coronary
syndrome
Signs and symptoms suggestive of recent
stroke
Known hypersensitivity
Relative contraindications:
Active ulcer disease
Blood thinner use
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
Can cause gastrointestinal upset and bleeding
Should be used with caution in patients who
report allergies to NSAIDs
Doses higher than recommended can actually
interfere with possible benefits
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Heartburn
Gastrointestinal bleeding
Nausea and vomiting
Wheezing
Prolonged bleeding
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Interactions
Given with other anti-inflammatory agents
may cause an increased incidence of side
effects and increased blood levels of both
Administration with antacids may reduce the
blood levels by decreasing absorption
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
325 mg prehospital
Equals four “baby” aspirin
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Alkalinizing Agents
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Alkalinizing Agents
Used to buffer the acids present in the body
during and after cardiac arrest and other
serious conditions
Normal body pH is 7.4 (7.35 to 7.45)
During hypoxia, the serum pH may fall quickly.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Alkalinizing Agents (cont.)
• Acid-base balance:
H+ + HCO3Acids
Bicarbonate
(strong)
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
H2CO2
H2O + CO2
Carbonic
acid
Water
Carbon
dioxide
©2005 Pearson Education, Inc.
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Sodium Bicarbonate
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Description
Class: Alkalinizing agent
A salt that provides bicarbonate to buffer
metabolic acidosis
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Mechanism of Action
• Was the cornerstone of ACLS care
• Controlled studies have shown that sodium
bicarbonate was ineffective in the treatment
of cardiac arrest.
• Associated with many adverse reactions
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Pharmacokinetics
Onset
Immediate
Peak effects
< 15 minutes
Duration
1-2 hours
Half-life
N/A
Prehospital Emergency Pharmacology, 6/e
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©2005 Pearson Education, Inc.
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Indications/Contraindications
Used late in cardiac arrest
Asystole/PEA with medical control approval
Tricyclic antidepressants overdose
Crush injury
No contraindications if used for the above
reasons
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Side Effects
Few side effects when used in the emergency
setting
Can cause metabolic alkalosis when
administered in large quantities
It is important to calculate the dosage based
on patient weight and size.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Interactions
Most catecholamines and vasopressors (e.g.,
dopamine and epinephrine) can be
deactivated by alkaline solutions.
Used in conjunction with calcium chloride, a
precipitate can form, clogging the IV line
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Dosage
1 mEq/kg IV bolus for overdose or
asystole/PEA
Consider additional doses if symptoms from
Tricyclic Antidepressant overdose persist or if
altered LOC or dysrhythmias
50 mEq IV for crush injury with suspected
hyperkalemia
Peaked T wave or widened QRS
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Cardiac Pain
Management
Analgesics
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Analgesics
Drugs that have proved effective in alleviating
pain
Used for the treatment of emergencies
involving the cardiovascular system, especially
myocardial infarction
Analgesics are covered in detail in Chapter 15.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Morphine Sulfate
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Description
Class: Narcotic analgesic
A central nervous system depressant
A potent analgesic
Also has mild hemodynamic properties
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Mechanism of Action
Acts on opiate receptors in the brain
Increases peripheral venous capacitance and
decreases venous return
Decreases myocardial oxygen demand
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Pharmacokinetics
Onset
Immediate (IV), 15-30 minutes (IM)
Peak effects
20 minutes (IV), 30-60 minutes (IM)
Duration
2-7 hours
Half-life
1-7 hours
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Indications
Severe pain associated with:
Myocardial infarction
Kidney stones
Other reasons
Pulmonary edema either with or without
associated pain
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Contraindications
Should not be used in patients who are
volume-depleted or severely hypotensive
A history of hypersensitivity
Patients with undiagnosed head injury or
abdominal pain
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Precautions
Has a high tendency for addiction/abuse
Classified as a Schedule II drug
Special considerations involved in handling
Naloxone (Narcan) should be available
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Side Effects
Nausea and vomiting
Abdominal cramps
Blurred vision
Constricted pupils
Altered mental status
Headache
Respiratory depression
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Interactions
The CNS depression associated with morphine
can be enhanced when administered with
antihistamines, antiemetics, sedatives,
hypnotics, barbiturates, and alcohol.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Dosage
Initial dose of 2-10 mg IV for cardiac
Additional 2 mg every 5 minutes
Initial dose 5-10mg slow IP for trauma/burns
Additional 5 mg every 5 minutes
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Nitrous Oxide
Nitronox, Entonox
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Class
 Analgesic and anesthetic gas
Prehospital Emergency Pharmacology, 6/e
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©2005 Pearson Education, Inc.
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Description
Analgesic and anesthetic gas
A blended mixture of 50% nitrous oxide and
50% oxygen
Has potent analgesic effects
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Mechanism of Action
A CNS depressant with analgesic properties
When inhaled, it has potent analgesic effects.
These effects dissipate quickly within 2-5
minutes after cessation of administration.
Nitronox must be self-administered.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
2-5 minutes
Peak effects
2-5 minutes
Duration
2-5 minutes
Half-life
Unknown
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications
Pain of musculoskeletal origin
Fractures
Burns
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Contraindications
Patient who cannot comprehend verbal
instructions
Patient who is intoxicated with alcohol or other
drugs
Head injury with an altered mental status
Thoracic injury suspicious of pneumothorax
Severe abdominal pain and distension,
suggestive of bowel obstruction
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
• Use in areas that are well ventilated
• In environments < 21°F, the liquid may be slow
to vaporize, and administration may be
impossible.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Side Effects
Dizziness
Light-headedness
Altered mental status
Hallucinations
Nausea and vomiting
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Interactions
Can potentiate the effects of other central
nervous system depressants:
Narcotics
Sedatives
Hypnotics
Alcohol
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Dosage
Should only be self-administered
Continuous administration until the pain is
significantly relieved or the patient drops the
mask
The patient care record should document the
duration of drug administration.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Diuretics
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Diuretics
CHF occurs when the heart loses its ability to
pump blood effectively.
Failure of the left side of the heart causes a
buildup of blood in the pulmonary circulation.
Failure of the right side of the heart results in
congestion of the peripheral circulation.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Furosemide
Lasix
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Description
Class: diuretic
A potent diuretic that inhibits sodium and
chloride re-absorption in the kidneys and
causes venous dilation
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Mechanism of Action
Causes venous dilation within 5 minutes
Causes a reduction in preload, thus decreasing
cardiac work
Diuretic effect begins 5-15 minutes after
administration
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Pharmacokinetics
Onset
5-10 min. (vasodilation), 5-30 min. (diuresis)
Peak effects
30 min. (vasodilation), 20-60 min. (diuresis)
Duration
2 hours (vasodilation), 6 hours (diuresis)
Half-life
30 minutes
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Indications/Contraindications
Congestive heart failure
Pulmonary edema
Usage in pregnancy should be limited to lifethreatening situations
Has been known to cause fetal abnormalities
Should not be administered to patients with a
known allergy to the sulfa class of medications
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Precautions
Dehydration, electrolyte depletion, and
hypotension.
Blood pressure should be frequently
monitored.
Should be protected from light
Transient deafness
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Side Effects
Headache
Dizziness
Hypotension
Volume depletion
Potassium depletion
Dysrhythmias
Diarrhea
Nausea and vomiting
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Dosage
40 mg slow IVP in patients already on chronic
oral furosemide therapy
20 mg slow IVP in patients who are not taking
the drug orally on a regular basis
Dosages as high as 80 to 120 mg IVP may be
indicated in severe cases.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Antianginal Agents
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Antianginal Agents
A common manifestation of advanced
cardiovascular disease is angina pectoris
From a narrowing of the coronary arteries due
to buildup of atherosclerotic plaques or
coronary artery vasospasm
Exercise and other stressful situations can
result in myocardial hypoxia, causing pain.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Nitroglycerin
Nitrostat
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Description
Class: Nitrate
Potent smooth muscle relaxant used in the
treatment of angina pectoris
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Mechanism of Action
Reduces cardiac work
Dilates the coronary arteries
Results in increased coronary blood flow and
improved perfusion of ischemic myocardium
Relief of ischemia causes reduction and
alleviation of chest pain.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
1-3 minutes (SL)
Peak effects
5-10 minutes (SL)
Duration
20-30 minutes (SL)
Half-life
1-4 minutes
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Indications/Contraindications
Chest pain associated with angina pectoris
Chest pain associated with acute myocardial
infarction
Acute pulmonary edema/CHF without
hypotension
Hypotension
Increased intracranial pressure
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Precautions
Patients may develop a tolerance
Deteriorates rapidly once the bottle is open
Should be protected from light
Monitor vital signs during administration
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Headache
Weakness and dizziness
Tachycardia
Hypotension
Orthostasis
Skin rash
Dry mouth
Nausea and vomiting
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Interactions
Severe hypotension when administered to
patients who have recently ingested alcohol
Causes orthostatic hypotension when used in
conjunction with beta-blockers
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Dosage
One tablet or spray (0.4 mg) sublingually for
routine angina pectoris or cardiac chest pain
Repeat in 5 minutes as needed
Usually, no more than three tablets or sprays
should be administered prehospitally.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Other
Cardiovascular
Drugs
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Epinephrine for Asthma/Allergies
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
•
•
•
•
Class: Sympathetic agonist
A naturally occurring catecholamine
A potent α- and β-adrenergic stimulant
Its effect on β-receptors is more profound.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Mechanism of Action
• Causes bronchodilation due to its effects on
β2-adrenergic receptors
• Used to treat the bronchoconstriction
accompanying asthma and COPD
• Also effective in treating bronchoconstriction
associated with anaphylaxis
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
3-10 minutes, subcutaneous (SC)
Peak effects
20 minutes (SC)
Duration
20-30 minutes (SC)
Half-life
N/A
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Indications
Bronchial asthma
Exacerbation of some forms of COPD
Anaphylaxis
Contraindication: Patients with underlying
cardiovascular disease or hypertension
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Precautions
Should be protected from light
Tends to be deactivated by alkaline solutions
Any patient receiving epinephrine 1:1000
should be carefully monitored for changes in
blood pressure, pulse, and ECG.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Palpitations
Anxiety
Tremulousness
Headache
Dizziness
Nausea and vomiting
Can cause myocardial ischemia
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
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Dosage
Asthma/COPD/Wheezing
1:1000 0.01mg/kg up to 0.3mg IM per medical
control
Allergic reaction
1:1000 0.3 to 0.5mg IM
Anaphylaxis
1:10,000 0.3 to 0.5 IVP. If no IV, 1:1000 0.3 to 0.5
IM
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Albuterol
Proventil, Salbutamol, Ventolin
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Description
• Sympathetic agonist
• A sympathomimetic that is selective for
β2-adrenergic receptors
• Selective β2-agonist with a minimal number of
side effects
• Causes prompt bronchodilation
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Pharmacokinetics
Onset
5-15 minutes (inhaled)
Peak effects
1-1.5 hours
Duration
3-6 hours
Half-life
< 3 hours
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Indications/Contraindications
Bronchial asthma
Reversible bronchospasm associated with
chronic bronchitis and emphysema
Known history of hypersensitivity
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
Vital signs must be monitored.
Caution should be used with:
Elderly patients
Those with cardiovascular disease
Those with hypertension
Lung sounds should be auscultated before and
after each treatment.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
•
•
•
•
•
•
•
•
•
•
Palpitations
Anxiety
Dizziness
Headache
Nervousness
Tremor
Hypertension
Arrhythmias
Chest pain
Nausea and vomiting
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Interactions
• Possibility of side effects increases when
administered with other sympathetic agonists
• β-blockers may blunt pharmacological effects
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Dosage (cont.)
• In a nebulizer, dose is 2.5 mg
– 0.5 mL of a 0.83% solution diluted in 2.5 mL of
normal saline
– Delivered over 5 to 15 minutes
– Set oxygen at 6L for optimum nebulization
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Methylprednisolone
Solu-Medrol
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Description
Corticosteroid and anti-inflammatory
A synthetic steroid with potent antiinflammatory properties
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
Inhibits many substances that cause
inflammation (cytokines, interleukin,
interferon)
Inhibits the synthesis of pro-inflammatory
enzymes
Considered an intermediate-acting steroid
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
Variable
Peak effects
4-8 days (IM)
Duration
1-5 weeks (IM)
Half-life
3.5 minutes
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Indications/Contraindications
Severe anaphylaxis
Asthma
COPD
No major contraindications in the acute
management of severe anaphylaxis
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
Single dose is all that should be given in the
prehospital phase of care.
Long-term steroid therapy can cause
gastrointestinal bleeding, prolonged wound
healing, suppression of adrenocortical
steroids.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Fluid retention
Congestive heart failure
Hypertension
Abdominal distension
Vertigo
Headache
Nausea
Malaise
Hiccups
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
125mg IVP
Previously only recommended for prolonged
transport, now encouraged for shorter
transports too.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Induction Agents
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Midazolam
Versed
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
Class: Sedative and hypnotic
A benzodiazepine with strong hypnotic and
amnestic properties
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
Binds to specific sites on gamma-aminobutyric
acid (GABA) Type A receptors within the brain
GABA is the major inhibitory neurotransmitter
of the central nervous system.
Has no direct effect on the GABA receptors,
but potentiates the effects of GABA within the
brain
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action (cont.)
Increased GABA levels cause sedation.
Used as a sedative and hypnotic
3-4 times more potent than diazepam
Has impressive amnestic properties
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
1.5 minutes (IV), 15 minutes (IM)
Peak effects
20-60 minutes
Duration
< 2 hours (IV), 1-6 minutes (IM)
Half-life
1-4 hours
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications/Contraindications
Premedication before cardioversion and other
painful procedures
Status epilepticus
Assisted intubation
Hypothermia for ROSC
Known history of hypersensitivity
Patients in shock with depressed V/S
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
Midazolam has more potential to cause
respiratory depression/arrest.
Emergency resuscitative equipment must be
available.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Laryngospasm
Bronchospasm
Dyspnea
Respiratory
depression/arrest
Drowsiness
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden






Amnesia
Altered mental status
Bradycardia
Tachycardia
PVCs
Retching
©2005 Pearson Education, Inc.
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Upper Saddle River, NJ 07458
Dosage
• Cardioversion/Pacing: 2.5mg slow IVP
• Status epilepticus: 2.5mg IV. Repeat x1 in 5 min
• Intubation: 2.5mg slow IVP until sedation is achieved up
to maximum 10 mg
• Induction of Hypothermia for ROSC: 0.15mg slow IVP up
to 10mg for shivering and sedation.
• Pediatric doses: see SMO’s or Broslow/Pediatric tape
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Glucagon
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
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Description
• Hormone and antihypoglycemic
• A protein secreted by the α cells of the
pancreas
• Used to increase the blood glucose level in
cases of hypoglycemia in which an IV cannot
be immediately obtained
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
When released, causes a breakdown of stored
glycogen to glucose
Also inhibits the synthesis of glycogen from
glucose
Both actions tend to cause an increase in
circulating blood glucose.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
5-20 minutes
Peak effects
30 minutes
Duration
1-2 hours
Half-life
N/A
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications/Contraindications
• Hypoglycemia
• β-blocker overdose
Glucagon is a protein, so hypersensitivity may
occur.
Known hypersensitivity to the drug
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
• Only effective if there are sufficient stores of
glycogen within the liver
• Drug of choice in the management of insulininduced hypoglycemia is D50W
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Hypotension
Dizziness
Headache
Nausea and vomiting
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
1 mg IM or IN
Powder and saline come in separate vials,
must be mixed together first.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
50% Dextrose in Water
D50W
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Description
Class: Carbohydrate
Dextrose is used to describe the six-carbon
sugar d-glucose.
Principal form of carbohydrate used by the
body
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Mechanism of Action
Dextrose supplies supplemental glucose in
cases of hypoglycemia.
Serious brain injury can occur if hypoglycemia
is prolonged.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Pharmacokinetics
Onset
< 1 minute
Peak effects
Variable
Duration
Variable
Half-life
N/A
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Indications/Contraindications
• Hypoglycemia
• No major contraindications to the IV
administration of D50W to a patient with
suspected hypoglycemia
• Should be used with caution in patients with
increased intracranial pressure because the
dextrose load may worsen cerebral edema
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Precautions
• Obtain a Glucometer reading and draw a
sample of blood before giving D50W.
• Therapy should always be guided by objective
data such as patient assessment findings and
blood glucose determination.
• Extravasation may occur when smaller veins
are used.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Side Effects
Tissue necrosis and phlebitis at the injection
site
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Dosage
• Standard dosage in hypoglycemia is 25 g (50
mL of a 50% solution) IVP
• Pediatrics
– > 8 years, 2 mL/kg of 50% solution
– 1 – 8 years
• 2 mL/kg of 25% solution
– Infants under 2months
• 4 mL/kg of 12.5% solution
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
EKG strip o’ the month
• Ectopic beats!
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Premature Ventricular Contractions
PVC – most common.
Early beat, big, wide, bizarre, because the ventricles are
big and not used to running the heart very often. QRS often faces different
direction than in normal complexes.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
PVC’s
They can look alike (unifocal) or
different (multifocal).
Two in a row is a couplet. Three is a triplet. More than
three is v-tach. A PVC every other beat is bigeminal or
bigeminy (see below). Every third beat is trigeminal or
trigeminy.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Premature Atrial Contractions/PACs
PAC – next most common. Early beat, p-wave
often looks different than other p-waves
because it’s coming from the atria itself instead
of the SA node.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
PAC’s
FYI, several PAC’s in a row is SVT/PSVT.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Premature Junctional Tachycardia
(PJC)
PJC – fairly rare.
Early beat, p-wave
may be inverted, after the QRS or
flat/not visible at all (hidden in QRS or
T-wave).
Several PJC’s in a row is junctional
tachycardia/SVT.
This is because the beat is originating
from the AV junction instead of the SA
node and has to go up as well as
down to trigger the atria.
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
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• Have a great day and stay safe!
Prehospital Emergency Pharmacology, 6/e
Bryan E. Bledsoe / Dwayne E. Clayden
©2005 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458