The Drugs We Use

[dropdeded]

Pokin around the internet, looking for info on the drugs used onboard an ambulance and in the field.

Any suggestions for decent links or sites for reliable info??

Soon to enroll in a Paramedic program and just passing time gathering useful info.

Thanks

ed

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[NYMDinMI]

Check out:
www.emtcity.com

Lots of info (and opinions, so be prepared) there on almost any topic you'd care to discuss. There are also many veterans there who are chock full 'o info.

 

[DropkickMurphy]

There are far more newbies and wannabes on EMTCity so be forewarned. PM me if you need anything. I'm one of the "veterans" from over there.

 

[Karl_Hungus]

To the OP: Here is our current medication list of drugs we carry on the trucks, alphabetical order with trade name in parenthesis as needed--

Adenosine
Albuterol
DuoNeb (albuterol and ipratroprium bromide)
Amiodarone
Aspirin
Atropine
Dextrose 50%
Diazepam (Valium)
Diphenhydramine (Benadryl)
Dopamine
Epinephrine
Etomidate
Fentanyl
Flumazenil (Romazicon)
Furosemide (Lasix)
Glucagon
Glucose paste
Lidocaine 2%, 1% with NaHCO3 buffer
Meperidine (Demerol)
Metoclopramide (Reglan)
Midazolam (Versed)
Morphine Sulfate
Naloxone (Narcan)
Nitroglycerine (Nitrostat spray, Nitroquick tablets and Tridil IV infusion)
Nitrous Oxide:Oxygen 50:50 (NitroNox)
Oxygen
Oxytocin (Pitocin)
Pralidoxime Chloride (2-PAM) {Mark I auto-injector with atropine}
Rocuronium Bromide
Sodium Bicarbonate 8.4%
Succinylcholine (Anectine)
Vasopressin


Hope that helps!

 

[12R34Y]

To the OP: Here is our current medication list of drugs we carry on the trucks, alphabetical order with trade name in parenthesis as needed--

Adenosine
Albuterol
DuoNeb (albuterol and ipratroprium bromide)
Amiodarone
Aspirin
Atropine
Dextrose 50%
Diazepam (Valium)
Diphenhydramine (Benadryl)
Dopamine
Epinephrine
Etomidate
Fentanyl
Flumazenil (Romazicon)
Furosemide (Lasix)
Glucagon
Glucose paste
Lidocaine 2%, 1% with NaHCO3 buffer
Meperidine (Demerol)
Metoclopramide (Reglan)
Midazolam (Versed)
Morphine Sulfate
Naloxone (Narcan)
Nitroglycerine (Nitrostat spray, Nitroquick tablets and Tridil IV infusion)
Nitrous Oxide:Oxygen 50:50 (NitroNox)
Oxygen
Oxytocin (Pitocin)
Pralidoxime Chloride (2-PAM) {Mark I auto-injector with atropine}
Rocuronium Bromide
Sodium Bicarbonate 8.4%
Succinylcholine (Anectine)
Vasopressin


Hope that helps!

why would you possibly give someone demerol in the field?

Never had the stuff in our trucks and never worked at a service that did have it.

Just curious as all of the ED's in my million plus city with 26 ED's have banned demerol from the hospital.

later

 

[Gatewayhoward]

There is a legend of a mythical, official National Resistry list of meds but when I was in medic school, my teachers couldn't find any.

 

[jbar]

Pokin around the internet, looking for info on the drugs used onboard an ambulance and in the field.

Any suggestions for decent links or sites for reliable info??

Soon to enroll in a Paramedic program and just passing time gathering useful info.

Thanks

ed

We have Cardizem (diltazem) for afib/aflutter
also just got Phenergan as an antiemetic, used to have Anzamet for that

 

[southerndoc]

Why in the world do you carry DuoNeb as opposed to individual ipratropium and albuterol? The DuoNeb brand is more expensive.

We also carried meperidine on the rigs where I worked, but it's no longer carried there. Of course I worked for a smaller, rural service where abuse was less likely.

Out of curiosity Karl, are you in Seattle?

 

[DropkickMurphy]

What?! No ketamine!!

 

[Karl_Hungus]

12R34Y: Meperidine is sort of a "leftover" from the days before we got fentanyl. If a patient had an allergy to morphine or if morphine didn't work on his/her pain, we used meperidine. Currently, it is just another weapon in the arsenal for treating pain.
Honestly, since fentanyl has been onboard, I haven't used morphine or meperidine for anything but cardiac chest pain (and then it was MSO4, obviously).

southerndoc : Our pharmacy watches the bottom line very closely, so I can only assume that DuoNeb isn't horribly expensive. In the emergency setting, it is nice not to have to measure out two individual respiratory meds, instead put one "bomb" into a nebulizer and get the medicine to the patient.
No, I don't work in Seattle, I work in a mid-sized city in Iowa. While present, risk of meperidine abuse in the pre-hospital setting is low.

jbar : I really would like to have a calcium channel blocker available, but we don't currently. They have been telling us for about 6 months that we are getting lopressor (beta-blocker, I know) but it hasn't shown up in med bags yet.

 

[Karl_Hungus]

What?! No ketamine!!

I get the joke, but yeah, if you think Demerol is bad...
Talk about "potential for abuse"!!!

 

[DropkickMurphy]

I've experienced an accidental dose of ketamine- Iwas stuck with a needle full of it during a case in the ED....the nursing student ran the needle into the palm of my hand with her thumb on the plunger of the syringe....I got just enough to send me into the emergence reaction- and personally can't understand why anyone would abuse that stuff.....

 

[a_ditchdoc]

In Israel, ketamine is used rather freely on the rigs. The medics here love it. Likewise, most Israelis are not overly concerned about abuse of meds as many of them are not under lock and key.

 

[DropkickMurphy]

In Israel, ketamine is used rather freely on the rigs. The medics here love it. Likewise, most Israelis are not overly concerned about abuse of meds as many of them are not under lock and key.

Personally I'm quite fond of using ketamine to facilitate intubation, especially in asthmatics and non TBI trauma cases. But that's just me....other people may hold other opinions.....

 

[Apollyon]

We have Cardizem (diltazem) for afib/aflutter
also just got Phenergan as an antiemetic, used to have Anzamet for that

Ugh - Anzamet to Phenergan? That's one hell of a step down. I'm sure it was due to the cost, but Phenergan is CRAP. They use it like candy down here (NC), and think nothing of it. When I was in NY, I saw it used ONCE - and that was the first dystonic reaction I ever saw. Here, I saw a woman that got Phenergan and Stadol, and she looked like she'd been ketamined - like she was dissociatively anesthetized.

Phenergan has a black box warning on it for 12 and under - in 5 or so years, I expect that Phenergan will be black-boxed like droperidol (although, when it happens for Phenergan, it will deserve it, not like droperidol). Can't come soon enough.

Hell, in my medic days, we had NOTHING for vomiting - except Benadryl!

 

[southerndoc]

Phenergan has a black box warning on it for 12 and under - in 5 or so years, I expect that Phenergan will be black-boxed like droperidol (although, when it happens for Phenergan, it will deserve it, not like droperidol). Can't come soon enough.

I recently reviewed an article comparing prices of various anti-emetics. I was shocked to see that phenergan was more expensive than Reglan!

Are any EMS services carrying Reglan? I remember during my paramedic days we carried Inapsine (droperidol). Stuff worked great, but of course was removed when it was black boxed. I think it was black boxed unnecessarily. Haldol has prolonged many more QT's than droperidol.

Karl, I don't think the seconds saved in using a DuoNeb v. separate ipratropium and albuterol really makes a difference. More convenient for you, yes. Better care for the patient, no.

 

[Karl_Hungus]

I recently reviewed an article comparing prices of various anti-emetics. I was shocked to see that phenergan was more expensive than Reglan!

Are any EMS services carrying Reglan? I remember during my paramedic days we carried Inapsine (droperidol). Stuff worked great, but of course was removed when it was black boxed. I think it was black boxed unnecessarily. Haldol has prolonged many more QT's than droperidol.

Karl, I don't think the seconds saved in using a DuoNeb v. separate ipratropium and albuterol really makes a difference. More convenient for you, yes. Better care for the patient, no.

As indicated on the list I posted, yes, we do carry Reglan. Anecdotally, it helps about 50% of the time on N/V patients.

My post regarding pre-measured respiratory medications was comparing a pre-loaded "bomb" to the multi-dose vial metered out with the eye-dropper-like dispenser. In other facilities that use the multi-dose vial, I have seen providers who grossly approximate the amount of med they give. There seems to be less precision when compared to a pre-load, and that was in a well-lit hospital during an 8 hour shift, not at 3 am in a poorly-lit bedroom.
At least when I trained, the instructors cautioned us about giving too much ipratroprium.
It is my opinion, using pre-loads removes at least a couple potential sources for medication error (which makes it better for the patient, as well as more convenient for the medic)
And again, the structure-functionist in me is pretty certain that it can't be that much more expensive than seperate pre-loads of ipratroprium and albuterol, or seperate multi-dose vials.
I would have to check with the pharmacy to get an exact price and get back to you.

 

[a_ditchdoc]

I have to say, I used phenergan quite a bit and was pleased with its performance. I never saw any dystonic reactions. The only problem was the major sedative effects. Often the physicians would be pissed because rendered the patient unable to answer questions appropriatey. My system has now moved to Reglan to avoid this. What do you guys think so far as the comparative effectiveness of these agents?

 

[12R34Y]

I have to say, I used phenergan quite a bit and was pleased with its performance. I never saw any dystonic reactions. The only problem was the major sedative effects. Often the physicians would be pissed because rendered the patient unable to answer questions appropriatey. My system has now moved to Reglan to avoid this. What do you guys think so far as the comparative effectiveness of these agents?

I prefer compazine to phenergan or reglan personally. It seems no one can ever agree on an anti-emetic.

Half of the community places only give zofran or kytril anyway. talk about killing a flea with a sledge hammer.

Zofran's first line now a bunch. not very cost effective, but stuff works.

My old ambo service also carries zofran now.

 

[DropkickMurphy]

The big problem with multi-dose albuterol is cross contamination. I've read several studies showing contamination of these containers (in the hospital) with various bacteria, including B. catarrhalis (sic?).

 

[DropkickMurphy]

I have bad memories of Compazine.....I was given it and I spent the rest of the evening staring at the ceiling because my neck muscles spasmed and I couldn't get them to relax. Give me Phenergan any day.....at least it knocks me out.

 

[southerndoc]

Zofran's first line now a bunch. not very cost effective, but stuff works.

I don't use it front line, but I don't chase people with 20 doses of Reglan before moving to Zofran.

Phenergan injection is about $2/dose, Reglan about $3/dose, and Zofran is $12/dose.

 

[EMS78]

I found if your doing just general research that medline is pretty decent.


MEDline











hope that helps,

 

[rn29306]

The only problem was the major sedative effects of phenergan. Often the physicians would be pissed because rendered the patient unable to answer questions appropriatey.

What dose are you guys giving? All 25 at once or divided 6.25 or 12.5mg?

I was given 25 mg IV and it rendered me (mid 20s, 6'2", 87kg) completely obtunded. I can't imagine what this does to elderly patients.

 

[rn29306]

Does anyone carry any type of induction drug?

Before I left my EMS company, I had to extensively teach the upper paramedics (level 3's as determined by in-house regulations and requirements) about Etomidate. It seems we were doing more and more head traumas that don't exactly well tolerate spikes in ICPs when trying to intubate on standard versed and morphine.

I know the studies about using Anectine and RSI wasn't exactly favorable in the field, but I was wondering about induction drugs alone.

 

[DropkickMurphy]

Personally, give my choice for induction (speaking from working in the ED as an RT, since I'm not EMT-P yet so I can't do it in the field), it would be ketamine with or without paralytic for for non-head trauma cases or medical cases as I said above. I have yet to see a case that mandated paralytics to intubate, but have seen them require to manage patients who were bucking the ventilator post-tube. Etomidate and vecuronium would be my choice for head trauma patients.

 

[emtcsmith]

I've seen valium(?) used to assist in intubation and I've heard rumors of getting one of the RSI drugs next to our box. In regards to cost my understanding that the hospital issues the boxes for the squads but who pays for it is beyond me.
*************
NOTICES
DEPARTMENT OF HEALTH
Approved Drugs for ALS Ambulance Services
[35 Pa.B. 4373]

Under 28 Pa. Code § 1005.11 (relating to drug use, control and security), the following drugs are approved for use by ground advanced life support (ALS) ambulance services and may be administered by emergency medical technician-paramedics, prehospital registered nurses and health professional physicians when use of the drugs is permitted by the applicable Department of Health (Department) approved regional medical treatment protocols:

1. Adenosine
2. Albuterol
3. Amiodarone
4. Aspirin
5. Atropine sulfate
6. Benzocaine--for topical use only
7. Bretylium
8. Calcium chloride
9. Dexamethasone sodium phosphate
10. Diazepam
11. Dilaudid--for interfacility transports only
12. Diltiazem
13. Diphenhydramine HCL
14. Dobutamine
15. Dopamine
16. Epinephrine HCL
17. Fentanyl
18. Furosemide
19. Glucagon
20. Heparin by intravenous drip--for interfacility transports only
21. Heparin lock flush
22. Hydrocortisone sodium succinate
23. Glycoprotein IIb/IIIa Inhibitors--for interfacility transports only
a. Abciximab
b. Eptifibatide
c. Tirofiban
24. Intravenous electrolyte solutions
a. Dextrose
b. Lactated Ringer's
c. Sodium chloride
d. Normosol
e. Potassium--for interfacility transports only
25. Ipratropium bomide
26. Isoproterenol HCL--for interfacility transports only
27. Levalbuterol--for interfacility transports only
28. Lidocaine HCL
29. Lorazepam
30. Magnesium sulfate
31. Metaproterenol
32. Methylprednisolone
33. Midazolam
34. Morphine sulfate
35. Naloxone HCL
36. Nitroglycerin by intravenous drip--for interfacility transports only
37. Nitroglycerin ointment
38. Nitroglycerin spray
39. Nitroglycerin sublingual tablets
40. Nitrous oxide
41. Oxytocin
42. Phenergan
43. Pralidoxime CL
44. Procainamide
45. Sodium bicarbonate
46. Sodium thiosulfate
47. Sterile water for injection
48. Terbutaline
49. Tetracaine--for topical use only
50. Verapamil

 

[12R34Y]

Personally, give my choice for induction (speaking from working in the ED as an RT, since I'm not EMT-P yet so I can't do it in the field), it would be ketamine with or without paralytic for for non-head trauma cases or medical cases as I said above. I have yet to see a case that mandated paralytics to intubate, but have seen them require to manage patients who were bucking the ventilator post-tube. Etomidate and vecuronium would be my choice for head trauma patients.

If you've never seen a case that mandated paralytics to intubate then you haven't intubated very many people or you've just been lucky.

There is a reason it is standard of care to do RSI in the ED when a tube is needed.

Have you never intubated someone who is in status with clenched jaws?

Have you never intubated someone who you just can't get muscle relaxation and their mouth to open even with etomidate or other sedative?

I wouldn't intubate WITHOUT a paralytic.......the studies are clear (this isn't up for argument).......there are higher success rates and better visualization for ETT tube placement with the use of paralytics.

later

 

[greytmedic]

In my system in Northern Illinois we used 5 mg versed. If they weren't sedated enough in a minute or so we pushed 0.5mg/kg etomidate(max dose of 40mg). Head trauma we pushed 1.5mg/kg lido in addition to versed (and etomidate if needed). And the cherry on top was good-ole, spray it on your partners coffee cup, benzocaine spray.

 

[DropkickMurphy]

If you've never seen a case that mandated paralytics to intubate then you haven't intubated very many people or you've just been lucky.

There is a reason it is standard of care to do RSI in the ED when a tube is needed.

Have you never intubated someone who is in status with clenched jaws?

Have you never intubated someone who you just can't get muscle relaxation and their mouth to open even with etomidate or other sedative?

I wouldn't intubate WITHOUT a paralytic.......the studies are clear (this isn't up for argument).......there are higher success rates and better visualization for ETT tube placement with the use of paralytics.

later

It's obvious in certain cases paralytics are going to be required....and as I said, I'm an EMT-I (ergo, I can't give paralytics nor ketamine in the field), so I am only speaking of the treatments the ED docs I have worked with as an RT preferred (often they ordered the drugs and let me intubate as the RT)- most preferring the etomidate/vecuronium or Versed/vecuronium approach, but a few used ketamine and Versed or ketamine/Ativan. I'm not arguing, just stating this is the approach I have seen used and what I would do if given the authority to do so (although my thinking has been corrected to a certain degree now).

One more point and then I will drop this.....I have no recollection of seeing a study regarding ketamine as an RSI agent in the prehospital setting, in comparison with anything else, and I am hesitant to draw a conclusion about one drug or combination of drugs based upon another drug or combo. I'm literally falling over tired now and I'm heading to bed, but I will do a lit search when I get up and report back.