Interfacility Medications
Wilton EMS
Jamie J. Barton EMT-P, CCEMT-P
The REMAC approved additional medications
during IFT for Mohawk Ambulance Paramedics.
These are provided by the sending hospital
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Acetylcysteine
Bivaliradin
Diazepam
Dobutamine (SCT only)
Esmolol (SCT only)
Fentanyl
Fosphenytoin
Heparin
Insulin
Levetiracetam
Lorazepam
Mannitol (SCT only)
Methylprednisolone
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Midazolam
Milrinone (SCT only)
Morphine
Nicardipine (SCT only)
Nitroprusside (SCT only)
Norepinephrine (SCT only)
Octreotide
Pantoprazole
Phenylephrine (SCT only)
Phenytoin
Potassium Chloride
Propofol
Vasopressin (SCT only)
Verapamil (SCT only)
--An updated formulary including these medications will be provided to
you…personal pharmacology references are strongly recommended--
Same Drug Class Permitted
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The REMAC has also approved us to add drugs as needed
within the same drug class as those already specifically approved.
If a new drug is encountered by dispatch, they call me and I
approve it or not as ALS or SCT. I will then ask that the crew
call me to discuss.
We will add frequently encountered drugs to the official
formulary.
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Cleviprex (SCT)
Nexium
Precedex (SCT)
Thorazine
Procainamide
Hypertonic saline
Plan
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Review each case and examine the formulary for each
medication discussed
Understand that each of these medications is given with a
written physician order and titrated per order or by formulary
according to parameters given by sending physician
Become familiar with each medication
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Indications
Contraindications
Dose ranges
Adverse effects
Assure that you have a drug reference that includes each of these
medications…and that you know your scope of practice!
After each case, answer related questions (you may use your
formulary as a reference…but not your partner please…do your
own work!)
IFT Checklist
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Crew Assignment
At the Sending Facility
During Transport
At the Receiving Facility
Documentation
Crew is assigned
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Confirm sending and receiving locations
Review patient information
Assure appropriate staff and equipment
Critical Care Transport Team will be given a
phone number to call for a more detailed report
by the caring nurse or the charge nurse.
At The Sending facility
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Receive report and review orders
Use appropriate precautions
Assess patient
Address any concerns
Establish priorities and a plan
Transfer patient to MAS stretcher and equipment
Obtain chart and radiographs
Reassess briefly
During Transport
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Be safe…buckle up and secure equipment!
Maintain appropriate precautions
Provide care!
Reassessments as appropriate
Follow orders
Fall back on protocols
Contact Medical Control if needed
Additional Staff
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If hospital staff is on board, work as a team
Highest level of training is in charge, but each
team member has strengths and responsibilities
At The Receiving facility
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Radio ahead
Face to face report to RN/MD staff
Move patient to hospital stretcher and
equipment
Answer questions (and ask questions!)
Restock and clean up
Documentation
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HPI should summarize key points of prehospital and in
hospital events
State why MAS is called
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Document care during transport
Summarize role of additional staff if present
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“to provide ALS care and transport to xyz hospital for
services not available at abc hospital”
Mention specific services you were called for (eg advanced
ventilator management, etc)
“I assisted the PICU RN/RT in the management of this
child”
Include written orders
Questions so far?
Case 1
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Called to Midsized Community Hospital to transport a
32 year old woman with an acute nontraumatic
subarachnoid hemorrhage.
History
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24hr severe headache, unrelieved by 20 ExtraStrength
Tylenol
Suffered seizure and brought in unresponsive by EMS
Treatment provided
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Intubated, CT confirmed SAH
Case 1 cont’d
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Meds running
Propofol at 50mcg/kg/min
 Dilantin 1000mg infusing at wide open rate
 Acetylcysteine 150mg/kg bolus going over 1 hr
 Cardene 5mg/hr
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Review Propofol
Propofol Question
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Your intubated patient suddenly becomes
hypotensive. Their propofol is running at
50mcg/kg/min. You should
A. extubate immediately
 B. decrease the rate of the propofol
 C. increase the rate of the propofol
 D. drive faster and stop checking the BP
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Review Dilantin
Dilantin Question
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You receive an order to run a dilantin infusion at
a wide open rate to complete the loading dose of
1500mg. Your adult 100kg patient has a BP of
80/40. You should
A. do as the doctor ordered, it’s a quick trip anyway
 B. recalculate what was ordered and politely question
the doctor about the rate
 C. Stop the dilantin. A seizure would increase the
blood pressure anyway.
 D. Drive faster and stop checking the BP
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Review Acetylcysteine
Acetylcysteine Question
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You are running the acetylcysteine at the
ordered rate when you note that your intubated
patient becomes agitated. You should
A. stop the acetylecysteine immediately
 B. slow the acetylcysteine
 C. Reassess the patient for causes of agitation
 D. Drive faster and stop paying such close attention
to the patient
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Review Cardene
Cardene Question (SCT)
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You have an order to run Cardene at 5mg/hr IV
to achieve a goal SPB of between 120140mmHg. You are provided with an infusion
that is labeled Nicardipine. You should
A. return this drug immediately as it is a controlled
substance
 B. run it at 5mg/hr
 C. refuse the transport as this drug is not in your
scope of practice
 D. Drive faster and stop being so particular
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Case 1 cont’d—forward thinking
(planning ahead)
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Expect possibility of
Seizure—need versed (or Valium or Ativan) orders,
consider other anticonvulsants (fosphenytoin,
keppra)
 Rising ICP—consider mannitol orders (SCT)
 Agitation—need sedation or analgesia orders
 Extubation—shut propofol, be prepared with BVM
and intubation equipment
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Review Valium/Ativan
Valium/Ativan Question
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When using Ativan to treat a seizure, the initial
dose for an adult patient is
A. 2-4mg IV
 B. 10mg IV
 C. Ativan is contraindicated in seizing patients
 D. Drive faster and pay no attention to the seizure
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Review Fosphenytoin
Fosphenytoin Question
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You have orders for fosphenytoin 20mg/kg in case of
seizure. You note that the route of administration is not
indicated on the order. You know that this drug can be
administered via which routes
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A. IV or IN
B. IV or IM
C. IN or Rectal
D. Drive faster and don’t bother with the fosphenytoin…
Review Keppra
Keppra Question
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Your orders indicate that you should administer
levetiracetam 1000mg IV during the transport.
This drug is being used for what reason?
A. sedation
 B. analesia
 C. seizure prevention or treatment
 D. Drive faster…who cares anyway
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Review Mannitol
Mannitol Question (SCT)
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You have just completed a Mannitol infusion
that was ordered for your patient with elevated
ICP. If all goes well, what would you expect to
see upon your reassessment of the patient in the
next 30 minutes?
A. they might wake up and say thank you
 B. cerebral herniation
 C. a full foley bag
 D. drive faster and stop with the reassessment thing
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Hypertonic Saline (3%)
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Hyperosmolar therapy treatment for intracranial
hypertension
2% to 23.5% used
Reduces cerebral edema by reducing brain water
(reducing mass effect) through osmotic effect
May reduce ongoing inflammation through immune
moducation
Improves cerebral blood flow through multiple
mechanisms
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Increases circulating blood volume, MAP
Administering Hypertonic Saline to Patients With Severe Traumatic Brain Injury
Diane Schretzman Mortimer, Jon Jancik
DisclosuresJ Neurosci Nurs. 2006;38(3):142-146.
HTS cont’d
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Dose typically 30-150ml/hr or more
Concentrations greater than 3% must be
through central line
Serum sodium must be monitored and not
exceed 155mmol/L
Target serum osmolarity is less than
320mOsmol/L
Contraindicated if serum Na less than normal
(risk of central pontine myelinolysis)
HTS
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You are given a 100ml bag of 23% saline
without specific orders for administration. You
know that:
It should only be given in a central line
 You should never administer this drug
 It will cause a rise in intracranial pressure if given
 You need to know the patient’s most recent
potassium level
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Case 2
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Respond to Smallville Hospital for IFT of a 69 year old
with upper gi bleed
History
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Known alcoholic with esophageal varices presented with
hematemesis and hypotension
Treatment provided
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IVs placed and crystalloids infused
PRBC and FFP transfused
Ngt placed
Octreotide 25 mcg/hr
Protonix 80mg bolus begun
Vasopressin 0.2 u/min
Review Blood Products
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You have nothing to review…at this time, NYS
does not permit the AEMT to handle blood
products in any way shape or form. If a patient
requires blood products (PRBC, FFP, Platelets,
etc) a nurse must accompany the patient.
Question Blood Products
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You receive report on this patient and the nurse tells
you that the plasma is nearly done infusing…she tells
you to just finish it off and she will take credit for the
infusion. You should
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A. tell her you would be happy to
B. kindly ask her to complete the infusion and take the bag
down since blood transfusion is outside your scope of
practice
C. refuse the patient transfer and go back in service
D. drive faster…maybe nobody will notice that plasma is
hanging.
Review Octreotide
Question Octreotide
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You have now reviewed your formulary entry
for octreotide (sandostatin). You recall that it is
used for what indication?
A. hypernatremia
 B. hyperglycemia
 C. esophageal variceal bleeding
 D. drive faster and stop thinking so much about this
stuff…
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Review Protonix
Question Protonix
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Your GI bleed patient has pantoprazole running
as a continuous infusion after a bolus was
completed. The appropriate dose of this
infusion is:
A. 8mg/hr
 B. 80mg/hr
 C. 0.8mg/hr
 D. Drive faster and don’t worry about the dose…it’s
a harmless medicine anyway
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Review Nexium
Question Nexium
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The protonix that was ordered for your patient
has run out and the nurse hands you a bag of
something labeled esomeprazole.
You are not approved to move this medication
 Ask for the order to be clarified and the proper drug
and dose written
 Call medical control immediately
 Just take it and stop asking questions
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Review Vasopressin
Question Vasopressin (SCT)
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During the 60 minute transport, you realize that your
med pump has died (you forgot to plug it in) and it has
erased the dose of vasopressin that you had
programmed in. Wanting to quickly restart it you would
do what:
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A. Bolus at 40 units IV
B. Run the drip wide open until you see the desired effects
C. Check the orders and reprogram the pump as ordered at
0.4 units/min
D. Drive faster and blame your partner for not plugging the
pump in.
Case 2 cont’d forward thinking
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Expect the possibility of
Hypotension—fluids and increased vasopressin
versus other pressors (Neosynephrine or Levophed
if SCT) Blood products if staff on board.
 Increased blood loss—same as above
 PEA arrest—hypovolemia likely cause
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Review Neosynephrine
Question Neosynephrine (SCT)
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Your SCT partner has decided to increase the
neosynephrine infusion. You expect which of
the following effects on the patients vital signs:
A. rise in HR
 B. rise in BP
 C. facial flushing
 D. drive faster and don’t worry about what your
partner is doing
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Review Levophed
(Norepinephrine)
Question Levophed (SCT)
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You hear your SCT partner asking the sending
physician for orders for Levophed for an IFT.
You assume your patient is at risk for which of
the following:
A. hypertensive emergency
 B. severe hypotension
 C. arrhythmia
 D. drive faster and quit eavesdropping…
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Case 3
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Called to move a 49 yo male to the “Big” hospital for
emergent cath and possible IABP
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History
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Smoker with hypertension and DM 10 hours of crushing CP.
Anterior-lateral STEMI found on ECG treated with lytics now pain
free but hypotensive with rales throughout
Treatment provided
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Aspirin 324mg
Nitroglycerin 20mcg/min
Milrinone 0.25mcg/kg/min
Dobutamine 2mcg/kg/min
Angiomax 0.75mg/kg IV bolus
Review Nitroglycerin
Question Nitroglycerin
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The STEMI patient you are moving is on
Nitroglycerin at 20mcg/min and begins to have
increasing chest pain. You expect that your
transport orders will allow what to be done with
that medication
A. stop it immediately
 B. decrease the infusion rate as it is way too high
 C. increase the infusion rate
 D. drive faster and don’t worry about the chest pain,
he’s going to cath anyway
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Review Milrinone
Question Milrinone (SCT)
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Milrinone is a preferred inotropic agent for that
patient with CHF for what reason?
A. it’s cheap
 B. it vasodilates pulmonary arterioles and decreases
systemic vascular resistance
 C. it vasoconstricts pulmonary arterioles and
increases systemic vascular resistance
 Drive faster and really…who cares
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Review Dobutamine
Question Dobutamine (SCT)
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Outbound to an IFT, you hear that the patient is
on Dobutamine. You recall that this drug is a
A. anticoagulant
 B. beta blocker
 C. inotropic agent
 D. drive faster and just be sure your orders cover it
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Review Angiomax
Question Angiomax
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During the transport of this STEMI patient, you
notice that the patient develops a nosebleed.
You conclude that
A. their blood pressure must be too high
 B. this is an expected adverse effect of the angiomax
 C. the angiomax must be running too slowly
 D. drive faster and tell them to quit picking their
nose
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Review Dopamine
Question Dopamine
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The STEMI patient you are moving is on 20
mcg/kg/min of Dopamine. Their BP is 150/90
and HR 130 sinus tach. They continue to have
chest pain. You would like to do what with the
Dopamine?
A. titrate down
 B. titrate up
 C. stop it right away
 D. drive faster and stop thinking you might make a
difference
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Review Heparin
Question Heparin
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If your STEMI patient was not on angiomax,
you can expect to be running heparin at what
rate
A. 100 units/hr
 B. 1000 units/hr
 C. 10,000 units/hr
 D. drive faster and stop worrying about theoreticals
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Question
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Your stemi patient develops VT with a pulse
and continues to mentate well. He has allergies
to lidocaine and amiodarone. What is the next
best medication to use and what is the dose?
Midazolam 10mg
 Protonix 80mg
 Procainamide 15mg/kg
 He’s SOL…that’s all you know…
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Review procainamide
Case 3 cont’d forward thinking
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You guessed it…be ready for arrest and plan to
stop milrinone and dobutamine if BP completely
tanks or arrest occurs
Case 4
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Asked to transport a 12 year old child in DKA to the
Pediatric Mecca
History
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Diabetic child presented with vomiting and glucose of 500,
pH 7.0
Treatment provided (wgt 50kg)
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1000ml bolus NS
Insulin 5 unit IV bolus
Insulin 5 units/hr infusion
0.45NS with 20KCl/L at 90ml/hr
Review Insulin
Question Insulin
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During the 3 hour transport of a child with
DKA on an insulin infusion to Boston, you
expect to frequently monitor
A. radio reception in case you need med control
 B. blood glucose levels
 C. blood calcium levels
 D. drive faster…that’s a really long trip!
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Review KCl
Question KCl
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The potassium infusion of 50mEq/500ml is
running on a med infusion pump but the pump
dies. You should
A. run the rest wide open
 B. carefully titrate the drip rate to infuse no faster
than 10-15mEq/hr
 C. shut the drip
 D. drive faster and curse the med pump
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Case 4 cont’d forward thinking
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Plan to add dextrose to fluids if blood glucose
falls below 250
If fluid boluses are required, assure they are
measured and NS is used.
Be sure pump is used to regulate KCl infusion
Case 5
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Begged to transport a 50 year old man with a thoracic
aortic dissection to the Vascular Miracle Center
History
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Pmh of HTN presented with tearing pain from chest into
back. CT shows ascending thoracic aortic dissection
Treatment
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Esmolol infusion titrated
up to 300mcg/kg/min
Aline placed
Review Esmolol
Question Esmolol (SCT)
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During the transport, the patient with an aortic
dissection develops symptomatic hypotension.
Your SCT partner titrates down the esmolol
infusion. How long do you expect it to take to
see an effect?
A. 60 minutes
 B. 5-10 minutes
 C. 510 minutes
 D. Drive faster…this drug confuses the heck out of
you
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Case 5 cont’d forward thinking
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Consider analgesia, antiemetics and/or
anxiolytics
Determine next drug to add for BP control if
these do not bring SBP within desired range
Consider Nipride or Cleviprex
Review Nipride
Question Nipride (SCT)
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You and your sct partner are discussing the
patient you are going to move with an aortic
dissection. The patient is on Nipride. You point
out that this drug has what effect on the blood
pressure:
A. increases it
 B. decreases it
 C. has no effect
 D. Drive faster and stop trying to be so smart
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Review Cleviprex
Clevidipine (Cleviprex)
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Your orders are to keep SBP between 100-110
using Clevidipine which you find running at
6mg/hr. Your next BP is 95/60. What is your
next action
Discontinue the cleviprex right away
 Recheck the blood pressure
 Titrate down to 4 or 5 mg/hr
 Divert to the closest hospital regardless of the
intended destination facility
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Case 6
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Transport requested from small trauma hospital to large
trauma hospital for a young man with a spinal injury
History
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20 year old male skied into a tree and has not been able to
move his legs since
CT shows T4 displaced fracture with impingment on the
cord. No other vital organs were injured
Treatment
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Analgesia and immobilization
Crystalloids 2000ml
Solumedrol 30mg/kg IV over 15 minutes then infusion to
begin
Review
Solumedrol/Methylprednisolone
Question Solumedrol
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The dose of Solumedrol that you expect to give
to your patient with a spinal cord injury during
transport is
A. 125mg IV bolus
 B. 1-2mg/kg IV bolus
 C. 30mg/kg then 5.4mg/kg/hr
 D. drive faster and just get him to the trauma center
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Case 6 cont’d forward thinking
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Prepare for hypotension refractory to fluids
Consider pressors such as Neosynephrine or
Levophed (if you are SCT or have staff aboard)
Prevent nausea/vomiting
Treat pain
Question
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Your spine injured patient is too hypotensive to
allow more opiate analgesia to be given yet he is
crying out with every bump in the road. What
options do you have?
Hold his hand
 Sing softly to him
 Use a low dose of ketamine
 Get in the front with your driver so you don’t have
to listen
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Review Ketamine
Another ICU sedative--Precedex
Sedative in Hospice Care-Thorazine
In Closing…
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When assessing an IFT patient, review the care already
provided, think about what might happen during the
move and assure that your orders cover what you might
need but don’t go above your scope of practice
Do not be afraid to ask questions…
You MUST know everything about the medications
your patient has received and has continuing…use your
drug reference!
Be more than an “ambulance driver”