Onslow County - Camp Lejeune
EMS System
Medication Formulary
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Onslow County EMS; Policy 22
Contents
0.9% SODIUM CHLORIDE ..................................... 3
ACETAMINOPHEN ................................................. 6
ACTIVATED CHARCOAL ..................................... 7
ADENOSINE ............................................................ 8
ALBUTEROL SULFATE ......................................... 9
ALTEPLASE ........................................................... 10
AMIODARONE HCL ............................................. 11
ASPIRIN .................................................................. 13
ATROPINE SULFATE ........................................... 14
CALCIUM CHLORIDE.......................................... 15
CALCIUM GLUCONATE ..................................... 16
CEFAZOLIN ........................................................... 17
CEFTRIAXONE ..................................................... 18
ORAL GLUCOSE .................................................. 19
DEXTROSE 5% IN WATER ................................ 20
DEXTROSE 10% ................................................... 21
DILTIAZEM ........................................................... 22
DIPHENHYDRAMINE .......................................... 23
ENALAPRILAT ...................................................... 24
EPINEPHRINE ....................................................... 25
EPI 1:1,000 ............................................................. 26
EPI 1:10,000 ........................................................... 27
EPI 1:100,000 ......................................................... 28
EPI 1:500,000 ......................................................... 29
ETOMIDATE .......................................................... 30
FAMOTIDINE ........................................................ 31
FENTANYL CITRATE .......................................... 32
GLUCAGON ........................................................... 34
HEPARIN ................................................................ 35
HYDROMORPHONE HCL.................................... 36
HYDROXOCOBALAMIN ..................................... 37
IBUPROFEN ........................................................... 38
IPRATROPIUM BROMIDE ................................... 39
Revised April 2020
KETAMINE HCL ....................................................40
KETOROLAC TROMETHAMINE ........................42
LABETALOL HCL .................................................43
LACTATED RINGERS ..........................................44
LEVALBUTEROL HCL .........................................45
LEVETIRACETAM ................................................46
LIDOCAINE HCL ...................................................47
LOPERAMIDE HCL ...............................................48
LORAZEPAM .........................................................49
MAGNESIUM SULFATE ......................................50
METHYLPREDNISOLONE ...................................51
METOCLOPRAMIDE ............................................52
MIDAZOLAM HCL ................................................53
NALOXONE HCL ..................................................55
NERVE AGENT KIT ..............................................56
PRALIDOXIME CHLORIDE ................................ 57
NICARDIPINE HCL ...............................................58
NITROGLYCERIN .................................................59
NITROGLYCERIN SL .......................................... 60
NITROGLYCERIN PASTE ................................... 60
NITROGLYCERIN DRIP ...................................... 60
NITROUS OXIDE ...................................................61
NOREPINEPHRINE BITARTRATE .....................62
ONDANSETRON....................................................63
OXYGEN .................................................................64
OXYMETAZOLINE HCL ......................................65
OXYTOCIN .............................................................66
PROMETHAZINE HCL .........................................67
PROPOFOL .............................................................68
RANITIDINE HCL .................................................69
ROCURONIUM BROMIDE ...................................70
SODIUM BICARBONATE ....................................71
SUCCINYLCHOLINE CHLORIDE .......................72
TRANEXAMIC ACID ............................................73
Color code: Green=Adult Protocol/Dose; Orange=Pediatric Protocol/Dose; Blue=All Ages Protocol/Dose
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Onslow County EMS; Policy 22
0.9% SODIUM CHLORIDE
Common names:
Class:
Action:
Normal Saline, NS, 0.9%NaCl
Isotonic Crystalloid Solution
Contains 9 g/L sodium chloride, 154 mEq/L sodium and 154 mEq/L chloride, utilized
as fluid and electrolyte replacement.
Indications:
Hypovolemia of numerous origins.
Contraindications:
-Hypersensitivity
-Pulmonary edema
Side Effects:
+Pulmonary/peripheral edema +Hypertension
Special Considerations: In large amounts, other physiological electrolytes may become depleted.
Large amounts of NS may contribute to acidosis
Onset & Duration:
Immediate
Protocols & Dose:
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Adult Asystole (AC1):
250mL IV/IO, qPRN, maximum 2L
Bradycardia (AC2):
250mL-2L IV/IO, unless acute CHF, maximum 2L
Chest Pain/STEMI (AC4):
*pearl: 250-500mL as pre-cath hydration
Allergic Reaction (AM1):
500mL IV/IO, qPRN, maximum 2L
Adult Diabetic (AM2):
250mL IV/IO, qPRN. Then infuse 150mL/hr
Dialysis/Renal Failure (AM3):
250mL, qPRN, max 1L if lungs remain clear
Hypotension/Shock (AM5):
Bolus 250mL IV, repeat to effect SBP > 90, 2L Maximum
Hemorrhagic Shock?:
250mL each bolus, 1L maximum
Newly Born (AO2):
10mL/kg IV/IO, may repeat x 1
Pediatric Asystole (PC1):
20mL/kg IV/IO, qPRN, maximum 60mL/kg
Pediatric Bradycardia (PC2):
20mL/kg IV/IO, qPRN x3, max 60mL/kg
Pediatric Allergic Reaction (PM1):
*pearl: Fluids titrated to maintain a SBP >70 + (2xAge)
Pediatric Diabetic (PM2):
10-20mL/kg IV/IO, if s/s of metabolic compromise, maximum 20ml/kg
Pediatric Hypotension/Shock (PM3):
*Cardiogenic
5-10mL/kg IV/IO, titrate to age appropriate SBP ≥ 70 + (2xAge)
Maximum 10mL/kg
*Hypovolemic/Distributive/Obstructive
20mL/kg IV/IO, titrate to age appropriate SBP ≥ 70 + (2xAge)
*Hypovolemic Shock
20mL/kg IV/IO, qPRN
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Onslow County EMS; Policy 22
Revised April 2020
Scene Rehabilitation Responder (SO2):
500mL IV/IO, Maximum 2L, Titrate to HR ≤ 100 and SBP ≥ 100mmHg
Radiation Incident (TB7):
*Eye involvement
Irrigate involved eye(s) for 15-30 min, qPRN
*Chemical exposure/burn
Flush contact area for 15 min
Hyperthermia (TE4):
(Adult) 500mL IV/IO, repeat to SBP> 90; Maximum 2L
(Pedi) 20mL/kg IV/IO, repeat to SBP> 70+ (2xAge) Maximum 60mL/kg
Hypothermia (TE5):
(Adult) 500mL IV/IO, repeat to SBP > 90, Maximum 2L
(Pedi) 20mL/kg IV/IO, repeat to SBP ≥ 70 + (2xAge) Maximum 60mL/kg
Abdominal Pain/Vomiting & Diarrhea (UP3):
(Adult) 250mL, qPRN to SBP ≥ 90; Maximum 2L
(Pedi) 20mL/kg, qPRN to SBP ≥ 70 + (2xAge); Maximum 60mL/kg
Syncope (UP16):
(Adult) 250mL Bolus, qPRN, Titrate SPB ≥ 90mmHg, Maximum 2L
(Pedi) 20mL/kg IV/IO, qPRN to SBP ≥ 70 + (2xAge), Maximum 60mL/kg
Back Pain (UP5):
(Adult) Bolus 250mL IV, Titrate to SBP ≥ 90, Maximum 2L
(Pedi) 20mL/kg IV/IO, Titrate to SBP ≥ 70 + (2xAge) Maximum 60mL/kg
Behavioral (UP6):
(Adult) 500mL Bolus IV/IO, then 150-200mL/hr, May repeat 500mL Bolus as
needed, Maximum 2L
(Pedi) 20-60mL/kg IV/IO, Maximum 60mL/kg
Suspected Sepsis (UP15):
(Adult) 30ml/kg, qPRN to SBP ≥ 90mmHg, MAP > 65mmHg
(Pedi) 30mL/kg IV/IO, qPRN to SBP ≥ 70 + (2xAge)
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Onslow County EMS; Policy 22
3% SODIUM CHLORIDE
Common Names:
Class:
Action:
Hypertonic Saline, 3% NaCl
Hypertonic Crystalloid Solution
Hypertonic fluids contain a higher concentration of solute
compared to plasma and interstitial fluid; this creates an osmotic gradient and drives
fluid from the interstitial space into the intravascular space. This increase in
intravascular volume increases mean arterial pressure (MAP), stroke volume (SV),
and cardiac output (CO) when compared with equal volumes of normal saline or
other isotonic fluids. There is also a significant increase in end-diastolic pressure
and a subsequent decrease in pulmonary vascular resistance. Hypertonic saline
requires less overall volume administered to achieve similar plasma volumes as
larger volumes of normal saline. Hypertonic saline increases the osmolarity of the
blood, which allows fluid from the extravascular space to enter the intravascular
space, which leads to decreases in brain edema, improved cerebral blood flow, and
decreased CSF production.
Indications:
-Hyponatremia
-Increased ICP
Contraindications:
-Pediatrics
-Administered IV ONLY, NO IO administration
Side Effects:
+Hypernatremia
+Metabolic Acidos
+Osmotic Demyelination Syndrome
Considerations:
Caution is necessary with hypertonic saline in patients with congestive heart failure
or renal insufficiency due to their already increased fluid and sodium loads.
Pregnancy Category C.
Onset & Duration:
Immediate onset with estimated duration of 2-4 hours.
Protocols & Dose:
Head Trauma (TB5)
100mL infused over 10 minutes, IV ONLY
Follow on infusion of 400mL over 50 minutes
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ACETAMINOPHEN
Common names:
Class:
Action:
Tylenol®, APAP, MAPAP
Non-narcotic analgesic, antipyretic
Inhibits the synthesis of prostaglandins that may serve as mediators of pain,
antipyretic effect via direct action on the hypothalamus.
Indications:
Used for fever ≥ 100.4* F and pain of mild, moderate, or severe intensity (alone or in
combination with opioids). May be preferred over NSAIDs due to fewer hematologic,
gastrointestinal, and renal effects.
Contraindications:
-Hypersensitivity
-Liver impairment/failure,
-Active hepatitis infection
Side Effects:
+Nausea/vomiting
+Constipation
+Allergic reactions
+Abdominal pain
Special Considerations: Use caution in patients with obstructive pulmonary disease
Onset & Duration:
Rapid onset, peaking 1-2 hours, duration 3-4 hours
Protocols & Dose:
Scene Rehabilitation Responder (SO2):
1000mg PO
Fever/Infection (UP10):
(Adult) 325-1000mg PO, Liver Disease: Max 600mg
(Pedi) 15mg/kg PO/PR
*PR Tylenol Dosing
(Adult) 1000mg
(Pedi) 15mg/kg
Pain Control (UP11):
15mg/kg (325-1000mg typical adult) Maximum 1000mg
Repeat & Max:
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May repeat every 4-6 hours as needed
Max 1000mg/dose or 4000mg/day if pt is ≥ 60kg
Max 1000mg/dose or 75mg/kg/day if pt is ≤ 60kg
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Onslow County EMS; Policy 22
ACTIVATED CHARCOAL
Class:
Action:
Absorbent
Activated charcoal is a fine black powder that binds and adsorbs ingested toxins
within the GI tract. It is commonly combined with a laxative, such as sorbitol, which
increases gastric motility, so the body may excrete the toxin quickly and reduce
constipation.
Indications:
Used for pts who have overdosed on oral medications/substances, or ingested oral
poisons/toxins less than one hour ago, that pose potential harm.
Use in intubated pts via NG tube is only advised when ingestion confirmed ≤ 1 hour
and substance is lethal.
Contraindications:
-Ingestion of strong corrosive, caustic, or petroleum solutions.
Side Effects:
+Nausea/vomiting
+constipation/diarrhea
Special Considerations: Will stain any surface including skin and clothing.
Precipitous within bottle may settle into a mass when stored upright, making it
difficult to administer. Shake well prior to administering, consider storing on its side.
Onset & Duration:
Immediate within the GI tract until excreted, typically within 6-8 hours
Protocols & Dose:
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Overdose/Toxic Ingestion (TE7):
1g/kg PO
*pearl: Give NG if substance is KNOWN to be adsorbed, and airway secured by
intubation
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Onslow County EMS; Policy 22
ADENOSINE
Common names:
Class:
Action:
Adenocard®
Antiarrhythmic
Adenosine produces electrophysiologic changes by stimulating adenosine-sensitive
potassium channels in the atrial and sinoatrial node, causing an outward flow of
potassium from the cardiac myocytic membrane, which also reduces the action
potential of atrioventricular cells, resulting in atrioventricular nodal blockade and
reduction of accessory-pathway antegrade refractoriness.
Indications:
Symptomatic tachycardic rhythms with a pulse. While adenosine is effective at
converting SVT rhythms due to accessory pathways, it can also be an effective
"diagnostic aid" in wide complex and atrial tachycardias, although it is ineffective at
managing them.
Contraindications:
-Sick sinus syndrome
-Bradycardia
-Hypersensitivity
-2nd and 3rd degree heart block
Side Effects:
+Facial flushing
+Lightheadedness
+Arrhythmias
+Headache
+Diaphoresis
+Palpitations
+Chest Pain
+Hypotension
+Shortness of breath
+Nausea
+Transient/Prolonged asystole
Special Considerations: May produce bronchoconstriction in patients with severe asthma or
bronchopulmonary disease.
The half-life is relatively short, ≤ 10 seconds. Therefore, a proximal, large-bore IV
site is preferred, followed by a 20 mL flush to assist in timely delivery to myocardial
cells.
Onset & Duration:
Successful administration will result in rhythm changes within seconds. Although the
drug’s half-life is short, successful conversion to a sinus rhythm usually lasts. Other
atrial/ventricular rhythms may slow enough to allow a diagnostic view before
resuming the initial rate.
Protocols & Dose:
Adult Tachycardia (narrow/reg:AC6)(wide/reg:AC7):
6mg IV/IO Rapid push with flush,
May repeat 12mg IV/IO
May repeat 12mg IV/IO
Pediatric Tachycardia (PC5):
0.1mg/kg IV/IO, Maximum 6mg,
May repeat 0.2mg/kg IV/IO, Maximum 12mg
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Onslow County EMS; Policy 22
ALBUTEROL SULFATE
Class:
Action:
Sympathomimetic bronchodilator
Selective beta2-adrenergic agonist that stimulates receptors of the smooth muscle in
the lungs, uterus, and vasculature supplying skeletal muscle.
Indications:
Acute bronchospasms associated with obstructive airway disease; moderate to severe
allergic reaction; symptomatic hyperkalemia with peaked T-waves and widened QRS,
secondary to renal failure or crush syndrome.
Contraindications:
-Hypersensitivity
-Severe Tachycardia
Side Effects:
+Restlessness
+Anxiety
+Palpitations
+Transient rise in BP
+Tachycardia
+Dry mouth
+Nausea/Vomiting
Special Considerations: Sympathomimetics may precipitate adverse cardiovascular effects
Onset & Duration:
Onset 5-15 minutes, peak 60-90 minutes, duration 3-6 hours
Protocols & Dose:
Allergic Reaction/Anaphylaxis (AM1):
Pediatric Allergic Reaction (PM1):
2.5-5mg via nebulizer, qPRN
Adult COPD/Asthma (AR4):
2.5-5mg via nebulizer, qPRN
Pediatric Asthma (AR7):
1.25-2.5mg via nebulizer, qPRN x3
*pearl (≤1yr=1.25mg; 1–6yrs=1.25–2.5mg; 6–14yrs=2.5mg; ≥ 15yrs=2.5–5mg)
Dialysis/Renal Failure (AM3):
2.5-5mg via nebulizer
Crush Syndrome (TB3):
2.5-5mg via nebulizer, qPRN x3
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Revised April 2020
Onslow County EMS; Policy 22
ALTEPLASE
Common names:
Class:
Action:
Activase®, t-PA
Fibrinolytic
Alteplase exerts its action on the endogenous fibrinolytic system to convert
plasminogen to plasmin by directly hydrolyzing the arginine-valine bond in
plasminogen. Plasmin degrades fibrin and fibrinogen as well as the procoagulant
factors V and VIII. Unlike streptokinase or urokinase, most of the activity of alteplase
is dependent on the presence of fibrin. Minimal amounts of plasminogen are
converted to plasmin in the absence of fibrin. Upon binding to fibrin, the one-chain
form of t-PA is converted to the two-chain form. Both forms have similar fibrinolytic
and plasminogen-activating potential; however, the one-chain t-PA is considerably
less active in the absence of fibrin. Alteplase that is bound to fibrin acquires a high
affinity for plasminogen, which is responsible for an increased activity at the fibrin
surface compared to the circulation.
Indications:
t-PA is utilized when conducting interfacility transfer of suspected stroke pts only
when the referring facility has initiated bolus and/or maintenance infusion.
Contraindications:
-Hypersensitivity
Side Effects:
+Anaphylaxis
+Angioedema
+Bleeding
+Bradycardia
+Arrhythmia
+Laryngeal edema
+Pulmonary edema
+AV block
Special Considerations: Use caution in pts with severe, uncontrolled hypertension.
Onset & Duration:
Rapid onset, duration 10 min after cessation of infusion.
Protocols & Dose:
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Suspected Stroke Activase/t-PA- Interfacility (AM6):
Verify bolus dose, Verify total dose. Stop/Continue infusion as appropriate.
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Onslow County EMS; Policy 22
AMIODARONE HCL
Common names:
Class:
Action:
Cordarone®
Antiarrhythmic
Although the exact mechanism is unknown, amiodarone is known to act on the
myocardium to delay repolarization and increase the duration of the action potential
without significantly altering conduction. Eliminated by hepatic metabolism.
Indications:
Ventricular arrhythmias or wide complex tachycardia with or without a pulse
Contraindications:
Iodine sensitivity as amiodarone incorporates iodine into its chemical structure
-Cardiogenic shock
-Hypotension/Hypovolemia
-Bradycardia
-Prolonged QT
-Second/Third degree heart block
Side Effects:
+Peripheral vasodilation
+Hypotension
+Bradycardia
+Prolonged QT
+Respiratory Distress
+Arrhythmias
+Angioedema
+Headache
+Dizziness
+Nausea/Vomiting
Special Considerations: Use with caution in pts already on beta-blocker therapy as it may cause severe
bradycardia.
When diluting, amiodarone should be mixed with D5W and not NS due to its
incompatibility.
Diluted concentrations are safe to store and administer in polyvinyl chloride or
polyolefin tubing/bags for up to 24 hours, causing no concern for prehospital
administration.
Onset & Duration:
Rapid onset, short duration with serum concentrations dropping to 10% within 30-45
minutes
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Onslow County EMS; Policy 22
Protocols & Dose:
Revised April 2020
Adult Tachycardia (Narrow/Reg:AC6):
150mg in 100mL of D5W, IV/IO, Infuse over 10 minutes
May repeat if narrow complex tachycardia recurs.
450mg in 250mL of D5W, 1mg/min (33mL/hr)
Adult Tachycardia (Wide/Reg/Mono:AC7)
150mg in 100mL of D5W, IV/IO, Infuse over 10 minutes.
May repeat if wide complex tachycardia recurs.
450mg in 250mL of D5W, 1mg/min (33mL/hr)
Adult Tachycardia (Wide/Irreg/Monomorphic:AC7):
150mg in 100mL of D5W IV/IO, Infuse over 10 minutes
May repeat if wide complex tachycardia recurs.
450mg in 250mL of D5W, 1mg/min (33mL/hr)
V-Fib /Pulseless V-Tach (AC8):
300mg IV/IO
If refractory: May repeat 150mg IV/IO
Pediatric Tachycardia (PC5):
5mg/kg IV/IO over 20-60 minutes
Maximum single dose 300mg
May repeat x2, Maximum total dose of 15mg/kg.
Pediatric V-Fib/Pulseless V-Tach (PC6):
Pediatric Post Arrest (PC7):
5mg/kg IV/IO (single dose Maximum 300mg)
May repeat x2 Maximum total dose of 15mg/kg
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Onslow County EMS; Policy 22
ASPIRIN
Common names:
Class:
ASA, Acetylsalicylic acid
Non-steroidal anti-inflammatory (NSAID), anti-platelet aggregator, analgesic,
antipyretic
Action:
Inhibits cyclooxygenase, which is responsible for prostaglandin synthesis associated
with pain, fever and inflammation. Inhibits platelet aggregation by acetylating
cyclooxygenase permanently disabling cellular function so that it cannot synthesize
prostaglandins and thromboxanes. Since thromboxane is important in clotting, its
absence does not allow blood to clot effectively.
Indications:
Chest pain/STEMI, treatment of mild pain.
Contraindications:
-Not for pediatrics ≤ 15 yrs old due to risk of Reye’s Syndrome
-GI Bleed/Ulcer
-Bleeding disorders
-Hypersensitivity
-Pregnancy
-Head trauma/stroke
-Renal failure
Side Effects:
+Abdominal Pain
+Nausea/Vomiting
+Prolonged bleeding
+Heartburn
+Shortness of breath
Special Considerations: Use with caution with pts known to have ASA/NSAID sensitive asthma
Onset & Duration:
Onset 5-30 min, peak in 15 min-2 hrs, duration 1-4 hrs
Protocols & Dose:
Chest Pain: Cardiac/STEMI (AC4):
81mg x 4 PO (chewed) Or 325mg PO
Pain Control (UP11):
(≥16 only) 324-650mg PO
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Revised April 2020
Onslow County EMS; Policy 22
ATROPINE SULFATE
Class:
Action:
Parasympatholytic/Anticholinergic
Atropine is a potent parasympatholytic, that inhibits the actions of acetylcholine at the
postganglionic parasympathetic neuroeffector sites. Small doses inhibit salivary and
bronchial secretions; moderate doses decrease GI motility, inhibit gastric acid
secretion, and may block nicotinic receptor sites at the autonomic ganglia and at the
neuromuscular junction. Blocks vagal impulses, thereby increasing SA node
discharge and enhancing AV conduction resulting in positive chronotropic and
dromotropic effects without and inotropic effects.
Indications:
Symptomatic bradycardia
Contraindications:
-A-Fib/A-Flutter
-Tachycardia
-Glaucoma
-Cardiovascular compromise due to hypovolemia
-Second/third degree heart block due to ineffectiveness
Side Effects:
+Pupil dilation
+Tachycardia
+Headache
+Dry mouth
Special Considerations: Use caution in suspected MI as increased cardiac demand will precipitate increased
injury of the myocardium.
Adverse effects may be seen when administered with other cholinergic agents,
digitalis, antihistamines, procainamide, antidepressants, and benzodiazepines.
Onset & Duration:
Rapid onset, peak in 2-4 min, half-life 2-3 hrs
Protocols & Dose:
Bradycardia (AC2):
0.5mg IV/IO, q3-5 minutes, maximum 3mg
Pediatric Bradycardia (PC2):
0.02mg/kg IV/IO, May repeat x 1
Minimum single dose: 0.1mg
Maximum single dose: 0.5mg
WMD-Nerve Agent (TE8):
*See nerve agent kit for dosing instructions
*If nerve agent kit is unavailable, dose atropine accordingly
(Adult) 2mg IV/IO/IM, q3-5 min until symptoms resolve
(Pedi) See Pearls, IV/IO/IM, q3-5 minutes until symptoms resolve
*pearl:
≤ 40 lbs (18 kg) = 0.5mg
40-90 lbs (18-40 kg) = 1mg
≥ 90 lbs (≥ 40 kg) = 2mg
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Onslow County EMS; Policy 22
CALCIUM CHLORIDE
Class:
Action:
Electrolyte
Replaces elemental calcium, which is essential for regulating excitation threshold of
nerves and muscles. Calcium is also essential for blood clotting mechanisms,
maintenance of renal function, and bone tissues. Calcium increases myocardial
contractile force and ventricular automaticity making it a strong inotropic agent.
Additionally, it serves as an antidote for magnesium sulfate and calcium channel
blocker toxicity. Calcium chloride has three times as much elemental calcium than
calcium gluconate.
Indications:
Calcium channel blocker overdose, cardiac arrest in pts with known renal
failure/dialysis, acute hyperkalemia/hypocalcemia with peaked T-waves w/ widened
QRS in dialysis and crush syndrome pts,
Contraindications:
-Hypersensitivity
-Renal/cardiac insufficiency
-Patients taking digitalis
-Hypercalcemia
-V-fib
Side Effects:
+Arrhythmias including bradycardia or cardiac arrest
+Syncope
+Nausea/vomiting
+Hypotension
+Necrosis with extravasation
Special Considerations: Calcium chloride will precipitate when used in conjunction with sodium bicarbonate,
Toxicity with digitalis, and may antagonize the effects of calcium channel blockers.
Onset & Duration:
Onset and peak are immediate.
Protocols & Dose:
Dialysis/Renal Failure (AM3):
1g IV/IO
Crush Syndrome (TB3):
(Adult) 1g IV/IO
(Pedi) 20mg/kg IV/IO
Give over 2-3 minutes
Overdose/Toxic Ingestion (TE7):
(Adult) 1g IV/IO
(Pedi) 20mg/kg IV/IO
Give over 2-3 minutes
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Revised April 2020
Onslow County EMS; Policy 22
CALCIUM GLUCONATE
Class:
Action:
Electrolyte
Replaces elemental calcium, which is essential for regulating excitation threshold of
nerves and muscles. Calcium is also essential for blood clotting mechanisms,
maintenance of renal function, and bone tissues. Calcium increases myocardial
contractile force and ventricular automaticity making it a strong inotropic agent.
Additionally, it serves as an antidote for magnesium sulfate and calcium channel
blocker toxicity. Calcium gluconate has three times less elemental calcium than
calcium chloride.
Indications:
Calcium channel blocker overdose, cardiac arrest in pts with known renal
failure/dialysis, acute hyperkalemia/hypocalcemia with peaked T-waves w/ widened
QRS in dialysis and crush syndrome pts,
Contraindications:
-Hypersensitivity
-Renal/cardiac insufficiency
-Patients taking digitalis
-Hypercalcemia
-V-fib
Side Effects:
+Arrhythmias including bradycardia or cardiac arrest
+Syncope
+Nausea/vomiting
+Hypotension
+Necrosis with extravasation
Special Considerations: Calcium gluconate will precipitate when used in conjunction with sodium
bicarbonate, Toxicity with digitalis, and may antagonize the effects of calcium
channel blockers.
Onset & Duration:
Onset and peak are immediate.
Protocols & Dose:
Dialysis/Renal Failure (AM3):
2g IV/IO
Crush Syndrome (TB3):
2g IV/IO
Overdose/Toxic Ingestion (TE7):
2g IV/IO
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Onslow County EMS; Policy 22
CEFAZOLIN
Common names:
Class:
Action:
Ancef®
Cephalosporin antibiotic
It inhibits the third and final stage of bacterial cell wall synthesis by preferentially
binding to specific penicillin-binding proteins (PBPs) that are located inside the
bacterial cell wall. Like all beta-lactam antibiotics, its ability to interfere with PBPmediated cell wall synthesis ultimately leads to cell lysis.
Indications:
Adult pts (≥18 years old) presenting with open fractures.
Contraindications:
-Severe penicillin allergy
-Cephalosporin/Cephamycin hypersensitivity
Side Effects:
+Angioedema
+Dizziness
+Anaphylaxis
+Nausea/Vomiting
+Diarrhea
+Bleeding
Special Considerations: Provider should attempt to collect blood labs prior to administering the antibiotic if
such action won’t delay care.
Cephalosporins may precipitate increased bleeding, use caution when administering
to pts on anticoagulant therapies.
Reconstitute vial with 10 mL of NS. May be given IV over 3-5 minutes or added to
100 mL NS bag for infusion over 5 minutes.
Onset & Duration:
Peak serum levels are reached soon after IV administration, elimination half-life ~1.8
hours.
Protocols & Dose:
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Extremity Trauma (TB4):
(≥18 years old) 1g IV/IO over 3-5 minutes
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Onslow County EMS; Policy 22
CEFTRIAXONE
Common names:
Class:
Action:
Rocephin®
Cephalosporin antibiotic
It inhibits the third and final stage of bacterial cell wall synthesis by preferentially
binding to specific penicillin-binding proteins (PBPs) that are located inside the
bacterial cell wall. Like all beta-lactam antibiotics, ceftriaxone's ability to interfere
with PBP-mediated cell wall synthesis ultimately leads to cell lysis.
Indications:
Pts presenting with symptoms of sepsis or CNS infections, meeting systemic
inflammatory response syndrome (SIRS) criteria, extremity amputation and/or open
fractures.
Contraindications:
-Severe penicillin allergy
-Cephalosporin/Cephamycin hypersensitivity
Side Effects:
+Bronchospasms
+Angioedema
+Anaphylaxis
+Nausea/Vomiting
+Shortness of breath
+Diarrhea
+Flushing
+Abdominal pain
+Rash
+Bleeding
Special Considerations: Cannot be administered/reconstituted with any calcium products including LR
Provider should attempt to collect blood labs prior to administering the antibiotic if
such action won’t delay care.
Ceftriaxone may precipitate an elevated INR in pts on warfarin, consider risk/benefit
prior to administration.
Onset & Duration:
IM route delayed peak 1.5-4 hrs while IV route has rapid onset, peak 30 min;
elimination exceeds 24 hrs.
Protocols & Dose:
Repeat & Max:
D
Suspected Sepsis (UP15):
50mg/kg up to 1g, IV/IO/IM
*CNS Infections:
100mg/kg, Maximum 2g
**Reconstitute in 3ml NS. Administer IM route in deep gluteal**
Pt can receive a repeat dose in 12-24 hrs, not to exceed 4g/day for adults, and 2-4
g/day for infant through adolescents.
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Onslow County EMS; Policy 22
ORAL GLUCOSE
Class:
Action:
Carbohydrate
Dextrose (aka. glucose) is one of the basic building blocks of all sugars. Glucose is a
monomer and is therefore readily processed in the blood. Through glycolysis glucose
is turned into pyruvate giving off a small amount of chemical energy (ATP). Insulin
turns excess glucose into glycogen when blood sugars are high. Glucose is a large
molecule that forms a ring, this structure is incapable of being absorbed into a cell
without a mediator (insulin) and therefore increases damage to epithelium as it floats
through the blood stream. It also causes an osmotic pressure as concentrations vary
across membranes, the pressure is less with lower concentrated solutions.
Indications:
Blood glucose ≤ 69 in an awake pt with the ability to protect their airway.
Contraindications:
-Hyperglycemia
-Inability to swallow
Side Effects:
+Hyperglycemia
+Airway compromise
Special Considerations: Disable/disconnect pt’s insulin pump prior to administering glucose solutions to
correct hypoglycemia.
When hypoglycemia is corrected, pt must consume protein/carbohydrate foods to
maintain blood glucose levels.
Onset & Duration:
Rapid absorption.
Protocols & Dose:
Adult Diabetic (AM2):
Consider Oral Glucose Solution if available
(1 tube=15 grams)
Pediatric Diabetic (PM2):
½ to 1 Tube If age appropriate
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Onslow County EMS; Policy 22
DEXTROSE 5% IN WATER
Common names:
Class:
Action:
D5W
Carbohydrate
Dextrose (aka. glucose) is one of the basic building blocks of all sugars. Glucose is a
monomer and is therefore readily processed in the blood. Through glycolysis glucose
is turned into pyruvate giving off a small amount of chemical energy (ATP). Insulin
turns excess glucose into glycogen when blood sugars are high. Glucose is a large
molecule that forms a ring, this structure is incapable of being absorbed into a cell
without a mediator (insulin) and therefore increases damage to epithelium as it floats
through the blood stream. It also causes an osmotic pressure as concentrations vary
across membranes. The pressure is less with D5 and D10, therefore they are used in
pediatrics.
Indications:
For use in the administration and dilution of medications not compatible with other
agents.
Contraindications:
-Hyperglycemia
-Suspected stroke
Side Effects:
+Hyperglycemia
+Tissue necrosis with extravasation
Special Considerations: Ensure patent IV/IO site to avoid tissue necrosis.
Onset & Duration:
Rapid absorption
Protocols & Dose:
Adult Tachycardia (Narrow/Reg: AC6):
Adult Tachycardia (Wide/Reg/Monomorphic: AC7):
Adult Tachycardia (Wide/Irreg/Monomorphic: AC7):
*as adjunct for amiodarone administration only
100mL of D5W IV/IO (initial and repeat dose)
250mL of D5W (maintenance dose)
Pediatric Tachycardia (PC5)
Pediatric V-fib/Pulseless V-tach (PC6)
Pediatric Post Resuscitation (PC7)
*as adjunct for amiodarone administration only
100mL of D5W IV/IO (initial and repeat dose)
250mL of D5W (maintenance dose)
D
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Onslow County EMS; Policy 22
DEXTROSE 10%
Common names:
Class:
Action:
D10
Carbohydrate
Dextrose (aka. glucose) is one of the basic building blocks of all sugars. Glucose is a
monomer and is therefore readily processed in the blood. Through glycolysis glucose
is turned into pyruvate giving off a small amount of chemical energy (ATP). Insulin
turns excess glucose into glycogen when blood sugars are high. Glucose is a large
molecule that forms a ring, this structure is incapable of being absorbed into a cell
without a mediator (insulin) and therefore increases damage to epithelium as it floats
through the blood stream. It also causes an osmotic pressure as concentrations vary
across membranes. The pressure is less with D5 and D10, therefore they are used in
pediatrics.
Indications:
Blood glucose ≤ 69 with the inability to consume oral solutions.
Contraindications:
-Hyperglycemia
-Suspected stroke
Side Effects:
+Hyperglycemia
+Tissue necrosis with extravasation
Special Considerations: Ensure patent IV/IO site to avoid tissue necrosis.
Disable/disconnect pt’s insulin pump prior to administering glucose solutions to
correct hypoglycemia.
When hypoglycemia is corrected, pt must consume protein/carbohydrate foods to
maintain blood glucose levels.
Onset & Duration:
Rapid absorption
Protocols & Dose:
Adult Diabetic (AM2):
100mL IV/IO
D10 repeat doses: 150mL IV/IO
May repeat until Blood Glucose is ≥ 80mg/dL
or patient’s normal range
Pediatric Diabetic (PM2):
2.5ml/kg IV/IO
Repeat as needed until mental status improves or
Patient’s normal range
D
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Onslow County EMS; Policy 22
DILTIAZEM
Common names:
Class:
Action:
Cardizem®
Calcium channel blocker
Calcium channels in myocardial and vascular smooth muscle cell membranes are
selective and allow a slow, inward flow of calcium that contributes to excitationcontraction coupling and electrical discharge (plateau phase of the action potential) of
conduction cells in the heart and vasculature. Diltiazem inhibits this influx, possibly
by deforming the channel, inhibiting ion-control gating mechanisms, and/or
interfering with the release of calcium from the sarcoplasmic reticulum. The resultant
decrease in intracellular calcium inhibits the contractile processes of the myocardial
smooth muscle cells, resulting in dilation of the coronary and systemic arteries and
improved oxygen delivery to the myocardial tissue. In addition, total peripheral
resistance, systemic blood pressure, and afterload are decreased.
Indications:
Symptomatic atrial fibrillation, atrial flutter, or SVT
Contraindications:
-Sick sinus syndrome
-Hypotension
-Second/Third degree heart block
-WPW and other accessory pathway reentry tachycardias
Side Effects:
+Headache
+Constipation
+Rash
+Nausea
+Nausea
+Flushing
+Edema
+Drowsiness
+Hypotension
+Dizziness
Special Considerations: Diltiazem prolongs AV node refractory periods without significantly prolonging sinus
node recovery time, except in patients with sick sinus syndrome. Concomitant use of
diltiazem with beta-blockers or digitalis may result in additive effects on cardiac
conduction
Onset & Duration:
Rapid onset, half-life 4-6 hours
Protocols & Dose:
D
Adult Tachycardia (Narrow/Reg:AC6)(Narrow/Irreg:AC6):
0.25mg/kg IV/IO, Over 2-3 minutes, Maximum 25mg
*If no improvement:
5-15mg/hr IV/IO Infusion
*If No Improvement in 15 minutes:
0.35mg/kg IV/IO Bolus; Maximum 25mg
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Onslow County EMS; Policy 22
DIPHENHYDRAMINE
Common names:
Class:
Action:
Benadryl®
Antihistamine, anticholinergic
Diphenhydramine blocks the effects of Histamine (H1 histamine) on the H1 receptor
site through a competitive competition for the peripheral H1 site. When
diphenhydramine is bound the H1 site cannot be stimulated preventing the effects of
histamines (swelling, etc...). As an H1 blocker diphenhydramine blocks the effects of
H1 on its receptor in the cortex as well this causes a change in the cortex neural
potassium channels causing neurons in the cortex to have a higher threshold to
depolarize. This results in an increase in sedation as a result of the H1 block. As an
antihistamine, diphenhydramine one of the most effective antihistamine.
Indications:
Mild to severe allergic reactions and dystonia; nausea/vomiting refractory to
antiemetics; Behavioral emergencies where the pt has aggression, violence, or
agitation that creates a threat to themselves or others.
Contraindications:
-Hypersensitivity
Side Effects:
+Seizures
+Hypotension
+Sinus tachycardia
+Sedation
Special Considerations: Can be a powerful CNS depressant and work to potentiate other sedatives.
Onset & Duration:
Onset within 15 min when given IV, peak 1-4hrs, half-life 2-10hrs
Protocols & Dose:
Allergic Reaction (AM1):
25-50mg PO/IV/IM/IO, if not already given PO
Pediatric Allergic Reaction (PM1):
1mg/kg IV/IM/IO/PO, if not already given PO
Abdominal Pain Vomiting & Diarrhea (UP3):
(Adult) 25-50mg IV/IM
(Pedi) 1mg/kg IV/IM; (Must be ≥ 3 months old)
Behavioral (UP6):
*pearl: for extrapyramidal reactions (dystonia)
(Adult) 50mg IV/IO/IM/PO
(Pedi) 1mg/kg IV/IO/IM/PO
D
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Onslow County EMS; Policy 22
ENALAPRILAT
Common names:
Class:
Action:
Vasotec®, Enalapril
Angiotensin converting enzyme (ACE) inhibitor
Enalapril competes with the natural substrate, angiotensin I, thereby inhibiting its
conversion to angiotensin II. Angiotensin II is a potent vasoconstrictor and a negative
feedback mediator for renin activity. Thus, when enalapril lowers angiotensin II
plasma levels, blood pressure decreases and plasma renin activity increases.
Indications:
Moderate to severe pulmonary edema secondary to hypertension.
Contraindications:
-Hypersensitivity
-History of angioedema with any ACE inhibitor
-Pregnancy
-Hypotension
Side Effects:
+Bradycardia
+Angioedema
+Bronchospasms
+Tachycardia
+Anaphylaxis
+Hypotension
+Chest pain
+Shortness of breath
Special Considerations: Toxicity is more likely in pts suffering from renal impairment.
Pts suffering severe volume depletion, on high dose diuretic therapy, hyponatremia,
or recent dialysis may suffer excessive hypotension after administration, use caution.
Onset & Duration:
Effects seen within 15 min, peak occurring 1-4 hrs with effects lasting up to 6 hrs,
half-life approximately 11 hrs.
Protocols & Dose:
D
CHF/Pulmonary Edema (AC5):
1.25mg IV/IO, given over 5 minutes
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Onslow County EMS; Policy 22
EPINEPHRINE
Class:
Action:
Sympathomimetic, endogenous catecholamine
Epinephrine has complex target organ effects. It is a potent agonist at both alpha- and
beta- receptors throughout the body except for the sweat glands and facial arteries.
Epinephrine is a nonselective adrenergic agonist; it stimulates alpha1-, alpha2-, beta1,
and beta2-adrenergic receptors, although the degree of stimulation at these receptors
may vary depending on the dose administered. Stimulation of alpha1-receptors by
epinephrine leads to arteriolar vasoconstriction. Stimulation of presynaptic alpha2receptors inhibits norepinephrine release via negative feedback while stimulation of
post-synaptic alpha2-receptors also leads to arteriolar vasoconstriction. Stimulation of
beta1-receptors induces a positive chronotropic and inotropic response. Stimulation of
beta2-receptors by epinephrine leads to arteriolar vasodilation, bronchial smooth
muscle relaxation, and increased glycogenolysis.
Indications:
Cardiac arrest, bradycardia, moderate to severe allergic reaction, severe hypotension,
reactive airway disease refractory to bronchodilators, and stridor/croup.
Contraindications:
-None in life threatening situations
Side Effects:
+Tachycardia
+Hypertension
+Arrhythmia
+Palpitations
+Chest pain
+Anxiety
+Diaphoresis
+Myocardial infarction
Special Considerations: Use caution in pts suffering hypertension/tachycardia, those with a history of
cardiovascular disease, or elderly pts > 65, consider reducing IM dose by half.
Onset & Duration:
IV route has immediate onset with short half-life < 5 min, continuous infusion
achieves steady peak state within 10-15 min.
IM route offers rapid onset, peak at 6-10 min, half-life 15-20 min. Study shows IM
absorption is more rapid at anterolateral thigh as opposed to deltoid due to increased
blood flow.
Nebulized/inhaled epi causes bronchodilation in under 1 min.
ET absorption is unpredictable.
D
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Onslow County EMS; Policy 22
EPI 1:1,000
Concentration:
1mg/mL = 1000mcg/mL
Protocols & Dose:
Allergic Reaction/Anaphylaxis (AM1):
Autoinjector if available
0.3-0.5mg if available IM; q5 minutes x1 if no
improvement
*EMTB* Contact Med Control for repeat doses of Epi 1:1
Pedi Allergic Reaction/Anaphylaxis (PM1):
≥30kg: Adult Epi Pen IM if available
<30kg: Epi Pen Jr IM if available
≥30kg: 0.3-0.5 mg IM
<30kg: 0.01mg/kg
Repeat x1 in 5 minutes if no improvement
*EMTB* Contact Med Control for repeat doses of Epi 1:1
Adult COPD/Asthma (AR4):
0.3-0.5mg IM
*Stridor
Nebulize 1mg in 2mL NS, May repeat x 1
Pedi Asthma/Respiratory Distress (AR7):)
0.01mg/kg IM, Maximum 0.3mg
*Stridor
Nebulize 1mg in 2mL NS, May repeat x 1
Pedi Asystole/PEA (PC1):
Pedi V-Fib/Pulseless V-Tach (PC6):
0.1mg/kg ETT, Maximum 2.5mg, q3-5 minutes
D
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Onslow County EMS; Policy 22
EPI 1:10,000
Concentration:
Mixing instructions:
1mg/10 mL = 0.1mg/mL = 100mcg/mL
-Waste 1mL from a 10mL NS flush
-Draw up 1mg (1mL) of epi 1:1,000 into same NS flush
-Shake well to create 10mL (0.1mg/mL) of epi 1:10,000
Protocols & Dose:
Adult Asystole/PEA (AC1):
V-Fib/Pulseless V-Tach (AC8):
1mg IV/IO; q3-5 minutes as needed
Pedi Asystole/PEA (PC1):
Pedi V-Fib/Pulseless V-Tach (PC6):
0.01mg/kg IV/IO Maximum Single Dose 1mg, q3-5 minutes as needed
Newly Born (AO2):
0.01mg/kg IV/IO, q3-5 minutes as needed
D
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Onslow County EMS; Policy 22
EPI 1:100,000
Concentration:
Mixing instructions:
Protocols & Dose:
1mg/100mL = 1000mcg/100mL = 10mcg/mL
Push-dose, Epi Push
-Draw up 0.1mg (0.1mL) of epi 1:1,000
-Inject into 10mL NS flush
-Shake well to create 10mL (10mcg/mL) of epi 1:100,000
or
-With 10mL syringe, draw up 0.1mg (1mL) of epi 1:10,000
-With same syringe, draw up 9mL NS
-Shake well to create 10mL (10mcg/mL) of epi 1:100,000
or
Drip
-Draw up 1mg (1mL) of epi 1:1,000
-Inject into 100mL NS bag or buretrol
-Shake well to create 100mL (10mcg/mL) of epi 1:100,000
Bradycardia (AC2): “Push-dose”
10mcg IV/IO, q3-5 minutes, Titrate to
SBP ≥ 90 mmHg
Allergic Reaction/Anaphylaxis (AM1): “Epinephrine Drip”
1ml each minute over 10 minutes or until symptoms resolve; IV/IO
Pedi Allergic Reaction (PM1): “Epinephrine”
IV/IO Per Agency Medical Director, see page 2 for instructions
*Info box:
1mL each minute over 10 minutes or until symptoms resolve
Hypotension/Shock (AM5): “Epi Push”
1ml of Epi 1:100,000
*Info box:
IV Push/IO Push: 1ml Epinephrine 1:100,000 q3-5 minutes
Airway, Drug Assisted (AR3):
2-5mcg/min IV/IO
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Onslow County EMS; Policy 22
EPI 1:500,000
Concentration:
Mixing instructions:
Protocols & Dose:
1mg/500 mL = 1000mcg/500mL = 2mcg/mL
Drip
-Draw up 1mg (1mL) of epi 1:1,000
-Inject into 500mL NS bag
-Shake well to create 500mL (2mcg/mL) of epi 1:500,000 drip
or
-Draw up 2mg (2mL) of epi 1:1,000
-Inject into 1000mL NS bag
-Shake well to create 1000mL (2mcg/mL) of epi 1:500,000 drip
Bradycardia (AC2): “Epinephrine Drip”
1-10mcg/min IV/IO,
Titrate to SBP ≥ 90mmHg
Pedi Bradycardia (PC2): “Epinephrine”
0.1-1mcg/kg/min IV/IO,
Titrate to age appropriate SBP ≥ 70 + (2 x Age)
Pedi Asystole/PEA (PC1): “Epinephrine”
Pedi Hypotension/Shock (PM3): “Epinephrine”
0.1-1mcg/kg/min IV/IO
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Onslow County EMS; Policy 22
ETOMIDATE
Common names:
Class:
Action:
Amidate®
Hypnotic
It appears to facilitate GABAminergic neurotransmission by increasing the number of
available GABA receptors, possibly by displacing endogenous inhibitors of GABA
binding. Etomidate produces clinical responses such as hypnosis. Based on animal
studies, etomidate induces neocortical sleep. These studies suggest the effects of
etomidate are at least partially due to depression of the brainstem reticular formation.
Indications:
Airway compromise/impending compromise requiring anesthesia to secure
intubation.
Contraindications:
-Hypersensitivity
-Sepsis
Side Effects:
+Hypoventilation/Apnea
+Anaphylaxis
+Dysrhythmia
+Nausea/Vomiting
+Laryngospasm
Special Considerations: Only for pts >12.
May cause adverse reaction in pts with liver/renal impairment, consider reduced dose.
Onset & Duration:
Rapid onset < 1 min, half-life 75 min
Protocols & Dose:
Temperature Management-Interfacility (AC10):
10-20mg IV/IO
Airway, Drug Assisted (AR3):
0.3mg/kg IV/IO
D
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Onslow County EMS; Policy 22
FAMOTIDINE
Common names:
Class:
Action:
Pepcid®
Histamine (H2) Antagonists
Competitively inhibits the binding of histamine to H2-receptors on the gastric
basolateral membrane of parietal cells, reducing basal and nocturnal gastric acid
secretions. It also decreases the gastric acid response to stimuli such as food, caffeine,
insulin, betazole, or pentagastrin. Famotidine reduces the total volume of gastric
juice, thus indirectly decreasing pepsin secretion. The drug does not appear to alter
gastric motility, gastric emptying, esophageal pressures, biliary secretions, or
pancreatic secretions.
Indications:
Mild to severe allergic reaction.
Contraindications:
-Hypersensitivity
Side Effects:
+Angioedema
+Bronchospasms
+Prolonged QT
+Excitation
+Headache
+Dizziness
+Anaphylaxis
Special Considerations: Pt’s hypersensitive to any H2 antagonist may experience cross-reaction.
Onset & Duration:
Onset 5-15 min, half-life 2.5-3.5 hrs
Protocols & Dose:
Allergic Reaction/Anaphylaxis (AM1):
20mg IV/IO/IM
Pedi Allergic Reaction (PM1):
0.5mg/kg IV/IO/IM, Maximum 20mg
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Onslow County EMS; Policy 22
FENTANYL CITRATE
Class:
Action:
Narcotic analgesic, opiate agonist
Opiates do not alter the pain threshold of afferent nerve endings to noxious stimuli,
nor do they affect the conductance of impulses along peripheral nerves. Analgesia is
mediated through changes in the perception of pain at the spinal cord (mu2-, delta-,
kappa-receptors) and higher levels in the CNS (mu1- and kappa3 receptors). The
actions of fentanyl are similar to those of morphine, although fentanyl has a more
rapid onset. Clinically, stimulation of mu-receptors produces analgesia, euphoria,
respiratory depression, miosis, decreased gastrointestinal motility, and physical
dependence. Kappa-receptor stimulation also produces analgesia, miosis, respiratory
depression, as well as, dysphoria and some psychomimetic.
Indications:
Acute moderate/severe pain, sedation for multiple purposes.
Contraindications:
-Hypotension
-Hypersensitivity
Side Effects:
+Respiratory depression
+Apnea
+Euphoria
+Hyper/Hypotension
+Tachy/Bradycardia
+Nausea/vomiting
+Chest wall rigidity
+Dizziness
+Laryngospasm
+CNS depression
Special Considerations: Rapid administration IV/IO may result in muscle rigidity of the chest/abd wall
Onset & Duration:
IV route: Onset immediate with peak within minutes, duration 30-60 min.
IM route: Onset 7-8 min, lasting 1-2 hrs.
IN route: Onset 10 min, peak 15-21 min, duration 30-60 min.
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Onslow County EMS; Policy 22
Protocols & Dose:
Revised April 2020
Bradycardia (AC2):
Adult Tachycardia
(narrow/reg:AC6)(narrow/irreg:AC6)(wide/reg:AC7)(wide/irreg:AC7):
50mcg IV/IO/IM/IN, q5 minutes, Max 100mcg **Sedation**
Chest Pain/STEMI (AC4):
1mcg/kg IV/IO/IM/IN,
Repeat 25mcg q20 minutes as needed, Maximum 200mcg
Target Temperature Management-Interfacility (AC10):
1mcg/kg IV/IO,
q5 minutes as needed, Maximum 200mcg
Post-intubation/BIAD Management (AR8):
(Adult) 1mcg/kg IV/IO/IM/IN,
q5 minutes as needed, Maximum 300mcg
(Pedi) 1mcg/kg IV/IO/IM/IN,
MAY repeat 0.5mcg/kg q5 minutes as needed, Maximum 2mcg/kg
Pediatric Pulmonary Edema/CHF (PC3):
*pearl: 1mcg/kg IV/IO, Max single dose 50mcg.
**Must speak with Medical Control**
Crush Syndrome Trauma (TB3):
(Adult) 50mcg IV/IO/IM/IN, q5 minutes, Max 100mcg
(Pedi) 1mcg/kg IV/IO/IM/IN,
If no improvement after 5 minutes 0.5mcg/kg IV/IO
Pain Control (UP11):
(Adult) 50-100mcg IV/IO/IM/IN, Repeat 50mcg q5 minutes as needed,
Maximum 200mcg
(Pedi) 1mcg/kg IV/IO/IM/IN, Repeat 0.5mcg/kg q5 minutes as needed,
Maximum 2mcg/kg
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Onslow County EMS; Policy 22
GLUCAGON
Common names:
Class:
Action:
GlucaGen®
Hormone
Increases blood glucose, causes relaxation of smooth muscle of the GI tract, and
positive inotropic and chronotropic effect on the heart. Increases in blood glucose are
secondary to stimulation of glycogenolysis. In liver and adipose tissue, glucagon
increases the production of adenylate cyclase, which catalyzes the conversion of ATP
to cAMP. Cyclic AMP then initiates a series of enzymatic reactions that include
activation of phosphorylase, which promotes the breakdown of glycogen to glucose.
As a result, blood glucose levels are increased within minutes of glucagon
administration.
Indications:
Symptomatic hypoglycemia when IV/IO access is delayed or not possible, esophageal
spasms secondary to food bolus.
Contraindications:
-Hypersensitivity
Side Effects:
+Tachycardia
+Nausea/vomiting
+Anaphylaxis
+Hypotension
Special Considerations: The degree to which glucagon increases blood glucose is dependent on the liver
glycogen reserves and the presence of phosphorylases, increase is not as great in
patients with type I diabetes as compared to those with type II diabetes.
Use caution in pts with known cardiovascular disease due to inotropic effects.
Glucagon causes glycogen depletion, pts should consume carbohydrates asap.
Onset & Duration:
Onset 5-20, peak 30 min, duration 1-2 hrs. Half-life 45 min.
Protocols & Dose:
Adult Diabetic (AM2):
1-2mg IM, q15 min if needed
Pediatric Diabetic (PM2):
0.1mg/kg IM (Maximum 1mg),
q15 minutes as needed to keep Blood glucose > 60mg/dL
Overdose/Toxic Ingestion (TE7):
(Adult) 2-4mg IV/IO/IM
(Pedi) 0.1mg/kg IV/IO/IM,
q15 minutes as needed
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Onslow County EMS; Policy 22
HEPARIN
Class:
Action:
Glycosaminoglycan anticoagulant
Heparin exerts its anticoagulant action by accelerating the activity of antithrombin III
(ATIII) to inactivate thrombin; however, heparin does not lyse existing clots. The
inability of heparin to inactivate surface-bound thrombin and factor Xa may explain
its limited efficacy in patients with unstable angina, high-risk coronary angioplasty,
and coronary thrombolysis. High doses of heparin also interfere with platelet
aggregation, which, in turn, prolongs the bleeding time, although commonly used
therapeutic doses heparin do not affect bleeding time. High-molecular-weight heparin
fractions have a greater effect on platelet function. It has been shown that the plateletaggregating activity of heparin can be directly related to its molecular weight.
Indications:
Acute and symptomatic MI with ST segment elevation that has been confirmed with
the receiving PCI center.
Contraindications:
-Hypersensitivity
-Aneurysm
-Head trauma
-Clotting disorders
-Recent significant trauma
-Active/suspected bleeding of any kind
-History of heparin-induced thrombocytopenia (HIT)
Side Effects:
+Anaphylaxis
+Bleeding
+Bronchospasm
+Injection site reaction
Special Considerations: Use caution in pts with known renal/hepatic disease
Use caution in pts already on anti-coagulant therapy due to increased bleeding risk,
consider consulting medical control.
Onset & Duration:
Immediate onset, half-life 2.5-5 hrs
Protocols & Dose:
Chest pain/STEMI (AC4):
60units/kg IV/IO, Maximum 4000units
**Must confirm STEMI via medical consult with receiving facility prior to
administration**
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Onslow County EMS; Policy 22
HYDROMORPHONE HCL
Common names:
Class:
Action:
Dilaudid®
Narcotic analgesic, opioid agonist
Hydromorphone is a potent µ-opiate receptor agonist. Opiates do not alter the pain
threshold of afferent nerve endings to noxious stimuli nor do they affect the
conductance of impulses along peripheral nerves. Analgesia is mediated through
changes in the perception of pain at the spinal cord and higher levels in the CNS. The
emotional response to pain is also altered. Clinically, stimulation of µ-receptors
produces analgesia, euphoria, respiratory depression, miosis, decreased
gastrointestinal motility, and physical dependence.
Indications:
Acute moderate/severe pain.
Contraindications:
-Hypersensitivity
-Active asthma
-Labor/Delivery
-Hypovolemia/Hypotension
-Respiratory depression
Side Effects:
+Nausea/vomiting
+Respiratory depression/apnea
+Hypotension
+Bronchospasm
+Bradycardia
+Anaphylaxis
+Sedation
Special Considerations: Will potentiate the effects of other CNS/respiratory depressants, including alcohol.
Consider reducing the initial dose in elderly pts.
Onset & Duration:
Rapid onset, peak 15 min, duration 1-4 hrs.
Protocols & Dose:
D
Pain Control (UP11):
Chest Pain/STEMI (AC4):
1mg IV/IO, q20 minutes x1
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Onslow County EMS; Policy 22
HYDROXOCOBALAMIN
Common names:
Class:
Action:
CyanoKit®, Hydroxycobalamin, Vitamin B12
Antidote
Cyanide binds rapidly with cytochrome a3, a component of the cytochrome c oxidase
complex in mitochondria. Inhibition of cytochrome a3 prevents the cell from using
oxygen and forces anaerobic metabolism, resulting in lactate production, cellular
hypoxia and metabolic acidosis. The action of hydroxocobalamin in the treatment of
cyanide poisoning is based on its ability to bind cyanide ions. Each
hydroxocobalamin molecule can bind one cyanide ion by substituting it for the
hydroxo ligand linked to the trivalent cobalt ion, to form cyanocobalamin, which is
then excreted in the urine.
Indications:
Known or suspected symptomatic cyanide poisoning.
Contraindications:
-None in emergency situations
Side Effects:
+Anaphylaxis
+Renal failure
+Hypertension
+Rash
+Nausea
+Headache
+Peripheral edema
+Pulmonary edema
+Dizziness
+Skin/Eye irritation
Special Considerations: May be incompatible with numerous medications, should be administered through
dedicated IV line.
Should be administered slowly over 15 minutes.
Onset & Duration:
Rapid onset, half-life 26-31 hrs
Protocols & Dose:
D
Carbon Monoxide/Cyanide (TE2):
70mg/kg IV/IO, Maximum 5g
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Onslow County EMS; Policy 22
IBUPROFEN
Common names:
Class:
Action:
Advil®
Non-Steroidal Anti-Inflammatory Drug (NSAID), analgesic, antipyretic
Ibuprofen competitively inhibits both cyclooxygenase (COX) isoenzymes, COX-1
and COX-2, by blocking arachidonate binding resulting in analgesic, antipyretic, and
anti-inflammatory pharmacologic effects. The anti-inflammatory mechanism of
ibuprofen is due to decreased prostaglandin synthesis via inhibition of COX-1 and
COX-2. Ibuprofen is effective in cases where inflammation has caused sensitivity of
pain receptors (hyperalgesia). It appears prostaglandins, specifically prostaglandins E
and F, are responsible for sensitizing the pain receptors; therefore, ibuprofen has an
indirect analgesic effect by inhibiting the production of further prostaglandins and
does not directly affect hyperalgesia or the pain threshold. Ibuprofen promotes a
return to a normal body temperature set point in the hypothalamus by suppressing the
synthesis of prostaglandins, specifically PGE2, in circumventricular organs in and
near the hypothalamus.
Indications:
Used for fever ≥ 100.4* F and mild pain.
Contraindications:
-Renal Impairment/Failure/Transplant
-Hypersensitivity
-NSAID sensitive asthma
-GI bleeding
-Gastric ulcer
-Clotting disorders
Side Effects:
+Angioedema
+Pulmonary edema
+Bronchospasm
+Anaphylaxis
+Shortness of breath
+Bradycardia
+Hypo/hypertension
+Bleeding
+Nausea/vomiting
Special Considerations: Avoid use in pts with severe heart failure or hypertension.
NSAID use should be avoided after the second/third trimester of pregnancy.
Will increase effects of anticoagulants, use caution in pts undergoing anticoagulant
therapy.
NSAIDs should be avoided in pts undergoing chemotherapy
Many pts are aware if they have been instructed not to use NSAIDs by their doctor, it
is good practice to ask.
Onset & Duration:
Onset 15-45 min, peak 1-2 hr, half-life ~2 hrs.
Protocols & Dose:
Scene Rehabilitation Responder (SO2):
400mg PO
Fever/Infection (UP10):
(Adult) 400-800mg PO, Liver Disease: 600mg Maximum
(Pedi) 10mg/kg PO (if age > 6 months)
Pain Control (UP11):
10mg/kg PO (400-800mg typical adult), Maximum 800mg
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Onslow County EMS; Policy 22
IPRATROPIUM BROMIDE
Common names:
Class:
Action:
Atrovent®
Anticholinergic, Parasympatholytic bronchodilator
Ipratropium antagonizes the action of acetylcholine by blocking muscarinic
cholinergic receptors. Blockade of cholinergic receptors decreases the formation of
cyclic guanosine monophosphate (cGMP). When administered by oral inhalation,
ipratropium exhibits antimuscarinic activity on the bronchial smooth muscle;
systemic effects are minimal. Compared with atropine, ipratropium is roughly twice
as potent as a bronchodilator, and it exhibits a more favorable ratio of bronchodilation
to inhibition of salivary secretion. Bronchodilation following inhalation of
ipratropium is secondary to local effects rather than a systemic effect. Ipratropium
does not possess anti-inflammatory properties.
Indications:
Acute bronchospasms associated with reactive or obstructive airway disease.
Contraindications:
-Hypersensitivity to ipratropium or atropine
-Narrow angle glaucoma
Side Effects:
+Bronchospasm
+Angioedema
+Anaphylaxis
+laryngospasm
+Tachycardia
+Hypotension
+Dry mucosa
+Palpitations
Special Considerations: Use caution in elderly pts and those already suffering from cardiac arrhythmia.
Onset & Duration:
Onset 15-30 min, peak 1-2 hrs, duration of effects 4-5 hrs, half-life 2 hrs.
Protocols & Dose:
Adult COPD/Asthma (AR4):
Pediatric Asthma (AR7):
0.5mg, qPRN x3
Repeat & Max:
FDA recommends no more than 4 doses/day (2mg max) as no benefit is noted at
higher doses.
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Onslow County EMS; Policy 22
KETAMINE HCL
Common names:
Class:
Action:
Ketalar®
Sedative hypnotic, nonbarbiturate dissociative anesthetic
Ketamine-induced analgesia is obtained without the induction of deep levels of
anesthesia. Increasing doses of ketamine result in anesthesia. The state of
unconsciousness it produces is trancelike and cataleptic in nature and has been
referred to as dissociative anesthesia. Ketamine appears to selectively interrupt
association pathways of the brain before producing somatesthetic sensory blockade. It
may selectively depress the thalamoneocortical system before significantly obtunding
more ancient cerebral centers and pathways. Ketamine non-competitively blocks Nmethyl-D-aspartate (NMDA) receptors. The activity on NMDA receptors may be
responsible for the analgesic as well as psychiatric (psychosis) effects. It is also a
potent bronchodilator due to its sympathomimetic activity, with no effects on
pharyngeal or laryngeal reflexes, leaving the pts airway intact.
Indications:
+Sedation during RSI +Dangerously combative
+Behavioral emergencies
+Pain control
+Post intubation sedation
Contraindications:
-Hypersensitivity
-Hypertension
Side Effects:
+Tachy/Bradycardia
+Arrhythmia
+Laryngospasm
+Anaphylaxis
+Respiratory depression/apnea +Nystagmus
Special Considerations: Give over 60 seconds to reduce pressor effects and subsequent rise in BP/ICP.
May exacerbate acute psychosis in pts with psychiatric history, such as schizophrenia.
Utilize low end of dosing ranges for elderly pts.
Use caution in pts with chronic cardiac diseases (angina, CHF, MI), as ketamine
causes substantial increase in myocardial oxygen demand.
Onset & Duration:
IV route onset of dissociation 15 seconds, anesthesia effects 30 seconds, duration 510 minutes. Analgesic effects last 20-45 min.
IM route rapid absorption, delayed effects with anesthesia occurring in 3-4 min,
lasting 12-25 min.
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Protocols & Dose:
Revised April 2020
Airway, Drug Assisted (AR3):
1.5-2mg/kg IV/IO, May repeat x1
*Hypoxic/Hypotension/Dangerously Combative:
Airway Management:
1.5-2mg/kg IV/IO
Airway Management+Dangerously Combative:
4mg/kg IM, max 400mg (behavioral)
1.5-2mg/kg IV/IO
Post-Intubation/BIAD Management (AR8):
2mg/kg IV/IO
Behavioral (UP6):
4mg/kg IM, max 400mg
Pain Control (UP11):
0.2mg/kg IV/IO, max 20mg.
Mix in 250mL NS, infuse over 10 minutes, q30 minutes
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KETOROLAC TROMETHAMINE
Common names:
Class:
Action:
Toradol®
Non-Steroidal Anti-Inflammatory Drug (NSAID), analgesic
Ketorolac competitively inhibits both cyclooxygenase (COX) isoenzymes, COX-1
and COX-2, by blocking arachidonate binding resulting in analgesic, antipyretic, and
anti-inflammatory pharmacologic effects. The anti-inflammatory mechanism of
ketorolac is due to decreased prostaglandin synthesis via inhibition of COX-1 and
COX-2. Ketorolac is effective in cases where inflammation has caused sensitivity of
pain receptors (hyperalgesia). It appears prostaglandins, specifically prostaglandins E
and F, are responsible for sensitizing the pain receptors; therefore, ketorolac has an
indirect analgesic effect by inhibiting the production of further prostaglandins and
does not directly affect hyperalgesia or the pain threshold.
Indications:
Moderate to severe pain
Contraindications:
-Renal Impairment/Failure/Transplant
-Hypersensitivity
-NSAID sensitive asthma
-GI bleeding
-Clotting disorders
-Active bleeding
-Headaches
-Abd Pain
-Open fractures/obvious deformity
Side Effects:
+Angioedema
+Pulmonary edema
+Bronchospasm
+Anaphylaxis
+Shortness of breath
+Bradycardia
+Hypo/hypertension
+Bleeding
+Nausea/vomiting
Special Considerations: Avoid use in pts with severe heart failure or hypertension.
NSAID use should be avoided after the second/third trimester of pregnancy.
Will increase effects of anticoagulants, use caution in pts undergoing anticoagulant
therapy.
NSAIDs should be avoided in pts undergoing chemotherapy
Many pts are aware if they have been instructed not to use NSAIDs by their doctor, it
is good practice to ask.
Onset & Duration:
Onset 30 min, peak 1-2 hrs, effect duration 4-6 hrs
Protocols & Dose:
D
Pain Control (UP11):
(Adult) 30mg IV/IO, 60mg IM, Maximum 60mg
(Pedi) 0.5mg/kg IV/IO/IM, Maximum 30mg
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LABETALOL HCL
Class:
Action:
Beta-blocker
Labetalol blocks beta1-receptors in the heart, beta2-receptors in bronchial and
vascular smooth muscle, and alpha1-receptors in vascular smooth muscle. The betablocking activity is three to seven times as potent as the alpha-blocking ability. In
contrast to other beta-blockers such as propranolol, labetalol does not appear to
decrease the glomerular filtration rate or renal blood flow, probably because of the
drug's balanced actions on both alpha- and beta-receptors and its minimal effect on
cardiac output. The result of labetalol's actions at alpha- and beta-receptors leads to
vasodilation and decreased total peripheral resistance, which results in decreased
blood pressure without a substantial decrease in resting heart rate, cardiac output, or
stroke volume.
Indications:
Narrow complex, symptomatic tachycardia that is stable in nature and refractory to
adenosine. Labetalol is also used for hypertension, defined as SBP ≥ 180 and/or DBP
≥ 105, that develops during interfacility (hospital to hospital) transfer of suspected
stroke pts only.
Contraindications:
-AV block
-Sick sinus syndrome
-Shock/Hypotension
-CHF/pulmonary edema
-Severe bradycardia
-AMI
-Acute/chronic asthma
-Hypersensitivity
Side Effects:
+Brady/Tachycardia
+Bronchospasm
+Anaphylaxis
+Laryngospasm
+Angioedema
+Hypotension
+Wheezing
+Shortness of breath
Special Considerations: Use caution in pts with liver disease, dosage reduction may be necessary.
Onset & Duration:
Onset 2-5 min, peak 5-15 min, duration 2-4 hrs. Half-life 2.5-8 hrs.
Protocols & Dose:
Adult Tachycardia (narrow/reg:AC6)(narrow/irreg:AC6):
10mg IV push over 5 minutes,
If no improvement in 5 minutes, 10mg IV push over 5 minutes
Suspected Stroke: Activase/t-PA Interfacility (AM6):
*if transferring hospital DID NOT initiate antihypertensive infusion:
10mg IV/IO
*if transferring hospital DID initiate antihypertensive infusion:
Increase drip 2mg/min, every 10 minutes,
Titrate SBP<180mmHg, DBP<105mmHg,
Maximum 8mg/min
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Onslow County EMS; Policy 22
LACTATED RINGERS
Common names:
Class:
Action:
LR
Isotonic crystalloid
Each 100 mL contains 300 mg sodium chloride, 310 mg sodium lactate, 30 mg
potassium chloride, 20 mg calcium chloride, with a pH 6.5 utilized as fluid and
electrolyte replacement.
Indications:
Volume replacement in the presence of thermal burns.
Contraindications:
-Pulmonary edema
Side Effects:
+Edema
Special Considerations: Excessive administration may lead to metabolic alkalosis.
Cannot be administered with ceftriaxone (Rocephin®).
Onset & Duration:
Immediate within vesicular.
Protocols & Dose:
Chest Pain/STEMI (AC4):
*pearl: 250-500mL as pre-cath hydration
Thermal Burn (TB9):
0.25mL/kg x (% TBSA) / hr, for up to the first 8 hours
Crush Syndrome Trauma (TB3):
Entrapped < 2 hours:
(Adult): 1L/hour IV/IO
(Pedi): 3x Maintenance rate
Entrapped > 2 hours:
(Adult): 500mL/hour IV/IO
(Pedi): Maintenance fluid rate
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LEVALBUTEROL HCL
Common Names:
Xopenex
Class:
Bronchodilator/Beta2-Adrenergic Agonist
Action:
Activation of beta2-adrenergic receptors in smooth muscles, relaxing smooth
muscles in all airways from trachea to terminal bronchioles. Increased cyclic AMP
are also associated with the inhibition of release of mediators from mast cells in the
airway. Acts as a functional antagonist to relax the airway irrespective of the
spasmogen involved, thus protecting against all bronchoconstrictor challenges.
Indications:
Treatment of bronchospasm in patients with reversible obstructive airway disease.
Contraindications:
-Hypersensitivity to Levalbuterol or racemic Albuterol
Side Effects:
-Palpitations -Chest pain
-Dizziness
-Tremors
Considerations:
-Paradoxical Bronchospasm -Worsening of Asthma
-Renal patients
Onset & Duration:
Onset time of <10 minutes with peak at 1.5 hours. Duration can last up to 6 hours.
Protocols & Dose:
Adult COPD/Asthma Respiratory Distress (AR4)
1.25mg via nebulizer
-Tachycardia -Headache
-Nervousness -Hypokalemia
Pediatric Asthma/Respiratory Distress (AR7)
1.25mg via nebulizer
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Onslow County EMS; Policy 22
LEVETIRACETAM
Common names:
Class:
Action:
Keppra®
Anticonvulsant
The precise mechanism of action of levetiracetam is not known. Its antiepileptic
effect does not appear to involve known mechanisms relating to inhibitory and
excitatory neurotransmission. In vitro studies show that levetiracetam, up to 1700
mcg/ml, did not result in significant ligand displacement at known receptor binding
sites. Second messenger systems, ion channel proteins, glutamate receptor-mediated
neurotransmission, muscimol-induced chloride flux, and gamma-aminobutyric acid
(GABA)-transaminase and glutamate decarboxylase activities were unaffected by
levetiracetam. Benzodiazepine receptor antagonists (e.g., flumazenil) had no effect on
levetiracetam's protection against seizures. Conversely, a stereoselective binding site
for the drug has been demonstrated to exist exclusively in synaptic plasma
membranes in the CNS, but not in peripheral tissue. In vitro and in vivo recordings of
epileptiform activity from the hippocampus have shown that levetiracetam inhibits
burst firing without affecting normal neuronal excitability. This suggests that
levetiracetam may selectively prevent hypersynchronization of epileptiform burst
firing and propagation of seizure activity.
Indications:
Status epilepticus refractory to two doses of benzodiazepines.
Contraindications:
-Hypersensitivity
Side Effects:
+Anaphylaxis
+Angioedema
+Hallucinations
+Psychosis
+Hypertension
+Nausea/vomiting
+Abd pain
Special Considerations: May cause acute psychosis in pts with history of psychosis or schizophrenia.
Can potentiate other CNS depressants.
Concomitant use with tricyclic antidepressants may lower seizure threshold.
Onset & Duration:
Rapid onset, peak ~1 hr, half-life 6-8 hrs.
Protocols & Dose:
Seizure (UP13):
(Adult): 500mg IV/IO, Over 15 minutes
(Pedi): 15mg/kg; IV/IO, Over 15 minutes
**MUST administer 2 doses of Benzodiazepines prior to administration**
Repeat & Max:
Max 3000mg/day IV/PO
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LIDOCAINE HCL
Class:
Action:
Antidysrhythmic, Sodium channel blocker
Lidocaine's antiarrhythmic effects result from its ability to inhibit the influx of
sodium through the "fast" channels of the myocardial cell membrane, thereby
increasing the recovery period after repolarization. It suppresses automaticity and
decreases the effective refractory period and the action potential duration in the HisPurkinje system, while not suppressing automaticity at the SA node. It suppresses
spontaneous depolarizations in the ventricles by inhibiting reentry mechanisms. Its
analgesics effects are through a reversible nerve conduction blockade by diminishing
nerve membrane permeability to sodium, decreasing the rate of membrane
depolarization, and increasing the threshold for electrical excitability.
Indications:
Monomorphic, wide-complex tachycardia, pulseless v-tach and v-fib.
Contraindications:
-Hypersensitivity
-WPW/Adam-Stokes syndrome
-Severe SA block
-Any AV block
-Bifascicular block
Side Effects:
+Anaphylaxis
+Angioedema
+Hypotension
+Bradycardia/Asystole
+Respiratory depression/arrest +Laryngospasm
+Malignant hyperthermia
+Skin flushing/hot flashes
Special Considerations: A bifascicular block is defined when two or more fascicles are involved in any
combo. LBBB is bifascicular because it involves both the L anterior and posterior
fascicles. RBBB alone is singular, but in the presence of either L anterior or L
posterior fascicular block, the combo is considered bifascicular.
Onset & Duration:
Immediate onset, duration of effects 10-20 min.
Protocols & Dose:
Adult Tachycardia (Wide/Reg/Monomorphic:AC7)
1mg/kg bolus IV/IO.
Repeat 1mg/kg bolus q15 minutes if needed.
Adult Tachycardia (Wide/Irreg/Monomorphic:AC7):
1mg/kg bolus IV/IO.
Repeat 1mg/kg bolus q15 minutes if needed.
V-Fib /Pulseless V-Tach (AC8):
1.5mg/kg IV/IO, may repeat if refractory at 0.75 mg/kg IV/IO
Pediatric Tachycardia (PC5):
1mg/kg IV/IO, Maximum 100mg,
Repeat 0.5mg/kg, Maximum 3mg/kg total
Pediatric V-Fib/Pulseless V-Tach (PC6):
Pediatric Post Arrest (PC7):
1mg/kg IV/IO.
Repeat 1mg/kg bolus q15 minutes, if needed.
*IO placement: Paramedics may give 10-20mg of 2% lidocaine through an
established IO for adult pts with IO infusion-related pain per state procedure
guidelines. May repeat up to 3x for a maximum of 60mg.
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Onslow County EMS; Policy 22
LOPERAMIDE HCL
Common names:
Class:
Action:
Imodium®
Anti-diarrheal
Loperamide interferes with peristalsis by a direct action on the circular and
longitudinal muscles of the intestinal wall to slow motility. It also may directly inhibit
fluid and electrolyte secretion and/or increase water absorption by increasing the
transit time of the intestinal contents.
Indications:
+Control of nonspecific diarrhea
+Chronic diarrhea from IBS
+Reduce discharge from ileostomies
Contraindications:
-Hypersensitivity
-GI bleeding/bloody stools
-Abd pain
-Constipation/GI obstruction
Side Effects:
+Anaphylaxis
+Angioedema
+Prolonged QT
+Arrhythmia
+Abd pain
+Nausea/vomiting
+Dizziness
+Headache
Special Considerations: Should not be used for bacterial gastroenteritis, food poisoning, as diarrhea is the
body’s protective process to reduce exposure to the infecting bacteria.
Not approved for use in pediatric pts <2 yrs
Not for use by nursing mothers
Onset & Duration:
Delayed onset PO 30-60 min, peak 5 hrs, duration 24 hrs.
Protocols & Dose:
Scene Rehabilitation Responder (SO2):
4mg PO
Repeat & Max:
Max 8mg/day PO, pediatric max dosage varies by age 3-6mg/day
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Onslow County EMS; Policy 22
LORAZEPAM
Common names:
Class:
Action:
Ativan®
Benzodiazepine, anticonvulsant, sedative
Benzodiazepines act at the level of the limbic, thalamic, and hypothalamic regions of
the CNS, and can produce any level of CNS depression required. The action of these
drugs is mediated through the inhibitory neurotransmitter gamma-aminobutyric acid
(GABA). Central benzodiazepine receptors interact allosterically with GABA
receptors, potentiating the effects of GABA and thereby increasing the inhibition of
the ascending reticular activating system. Benzodiazepines block the cortical and
limbic arousal that occurs following stimulation of the reticular pathways. As an
anticonvulsant lorazepam is preferred, because even though it has a shorter half-life
than diazepam, lorazepam persists in the CNS longer.
Indications:
Seizure activity; For sedation during cardioversion/cardiac pacing procedures; And
behavioral emergencies where the pt has aggression, violence, or agitation that
creates a threat to themselves or others.
Contraindications:
-Hypersensitivity
Side Effects:
+Anaphylaxis
+Respiratory depression/arrest
+Cardiac arrest
+Pulmonary edema
+Bradycardia
+Hypo/hypertension
+Dizziness
+Drowsiness
+Nausea/Vomiting
+Delirium/confusion
Special Considerations: May potentiate other CNS depressants, including alcohol.
Use caution in pts with acute exacerbation of reactive/obstructive airway diseases,
due to respiratory depression.
Avoid in pts with neuromuscular disease and late-stage Parkinson’s.
Onset & Duration:
Rapid onset, half-life 12 hrs.
Protocols & Dose:
Bradycardia (AC2):
0.5-1mg IV/IO/IM, Maximum 10mg (Sedation)
Adult Tachycardia (narrow/reg:AC6)(narrow/irreg:AC6):
0.5-1mg IV/IO, Maximum 2mg (Sedation)
Adult Tachycardia (wide/reg:AC7)(wide/irreg:AC7):
0.5-1mg IV/IO, May repeat as needed, Max 2mg (Sedation)
Obstetrical Emergency (AO3):
0.5-1mg IV/IO, max 2mg
Seizure (UP13):
(Adult) 2mg IV/IO, repeat 2mg q2 minutes as needed, max dose 10mg
(Pedi) 1mg IV/IO, repeat 1mg q2 minutes as needed, max dose 5mg.
Behavioral (UP6):
(Adult) 2mg IV/IO
(Pedi) 0.1mg/kg IV/IO
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MAGNESIUM SULFATE
Class:
Action:
Electrolyte, anticonvulsant,
It is the second most plentiful cation of the intracellular fluids. It is essential for the
activity of many enzyme systems and plays an important role with regard to
neurochemical transmission and muscular excitability. Magnesium sulfate reduces
striated muscle contractions and blocks peripheral neuromuscular transmission by
reducing acetylcholine release at the myoneural junction. Additionally, Magnesium
inhibits Ca2+ influx through dihydropyridine-sensitive, voltage-dependent channels.
This accounts for much of its relaxant action on vascular smooth muscle.
Indications:
Used for immediate control of life-threatening convulsions due to preeclampsia/eclampsia during pregnancy; Also indicated for magnesium deficiency as
indicated by persistent ventricular fibrillation or torsades de pointes; Acute
exacerbation of reactive/obstructive pulmonary disease with impending failure and/or
refractory to bronchodilators.
Contraindications:
-AV block
-Hypotension
-AMI
-Hypocalcemia
Side Effects:
+Flushing/sweating
+Eye/Skin irritation
+Weakness/paralysis
+CNS depression
+Respiratory paralysis
+Hypocalcemia
+Hypotension
+High degree heart block
Special Considerations: Use caution in pts with renal insufficiency.
Onset & Duration:
IV route provides immediate onset, duration ~30 min.
IM route is significantly delayed, onset ~1 hr, duration 3-4 hrs.
Protocols & Dose:
Adult Tachycardia (wide/irreg/polymorphic:AC7):
*pearl: 2g slow IV/IO
Pediatric Tachycardia (PC5):
*pearl: 40mg/kg IV/IO over 10 minutes. Cardiac arrest given over 2 minutes.
Ventricular Fibrillation/Pulseless V-Tach (AC8):
2g IV/IO
Pediatric V-Fib/Pulseless V-Tach (PC6):
40mg/kg IV/IO over 10-20 minutes.
*Persistent VF/VT or Torsades de Points:
40mg/kg IV/IO over 1-2 minutes, q5 minutes, Max 2g
Obstetrical Emergency (AO3):
4g IM in each buttock (Total of 8g)
THEN: 4g IV/IO over 3-5 minutes
Adult COPD/Asthma (AR4):
2g IV/IO, infuse over 10 minutes
Pediatric Asthma/Respiratory Distress (AR7):
40mg/kg IV/IO, infuse over 10-20 minutes
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Onslow County EMS; Policy 22
METHYLPREDNISOLONE
Common names:
Class:
Action:
Solu-Medrol®
Systemic Corticosteroids, glucocorticoid
Glucocorticoids are naturally occurring hormones that prevent or suppress
inflammation and immune responses. At the molecular level, unbound
glucocorticoids readily cross cell membranes and bind with high affinity to specific
cytoplasmic receptors. This binding induces a response by modifying transcription
and, ultimately, protein synthesis to achieve the steroid's intended action: inhibition of
leukocyte infiltration at the site of inflammation, interference in the function of
mediators of inflammatory response, and suppression of humoral immune responses.
Indications:
Moderate to severe allergic reactions; hypotension/shock secondary to possible
adrenal insufficiency; Respiratory distress secondary to reactive/obstructive
pulmonary diseases.
Contraindications:
-Hypersensitivity
-Systemic fungal infection
-Acute pulmonary edema
-Acute hypertension
Side Effects:
+Anaphylaxis
+Increased blood coagulation
+Brady/Tachycardia
+Pulmonary edema
+Angioedema
+Hypertension
+Palpitations
+Nausea/vomiting
+Anxiety/restlessness
+Syncope
+Hyperglycemia
Special Considerations: Use caution in pts with recent MI due to possibility of left ventricular rupture.
Use caution in pts with thyroid disorders.
Monitor pts with diabetes for signs of hyperglycemia.
Consider diluting prior to administering IV/IO to avoid pt discomfort.
Onset & Duration:
Onset 1 hr, half-life 6-9 hrs.
Protocols & Dose:
Allergic Reaction/Anaphylaxis (AM1):
125mg IV/IO
Pediatric Allergic Reaction (PM1):
2mg/kg IV, Maximum 125mg
Hypotension/Shock (AM5):
Pediatric Hypotension/Shock (PM3):
*pearl: In suspicion of acute adrenal insufficiency/congenital adrenal hyperplasia
125mg IM/IV/IO
Adult COPD/Asthma (AR4):
125mg IV/IO/IM
Pediatric Asthma/Respiratory Distress (AR7):
2mg/kg IV/IO/IM, Maximum 125mg
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METOCLOPRAMIDE
Common names:
Class:
Action:
Reglan®
Antiemetic
Metoclopramide enhances gastric motility without stimulating gastric secretions.
Peripherally, metoclopramide augments cholinergic activity either by causing release
of acetylcholine from postganglionic nerve endings or by sensitizing muscarinic
receptors on smooth muscle. Centrally, metoclopramide blocks dopaminergic
receptors in the chemoreceptor trigger zone by antagonizing the actions of
apomorphine, a known central dopamine agonist. Antiemetic effects of are the result
of both the central dopamine antagonism and increased gastric motility.
Indications:
Nausea
Contraindications:
-Hypersensitivity
-Hypersensitivity to procainamide
-GI bleeding/bloody stools
-GI obstruction/perforation
-Acute pulmonary edema
Side Effects:
+Laryngospasm
+AV block
+Brady/Tachycardia/SVT
+Bronchospasm
+Angioedema
+Hypo/Hypertension
+Nausea/vomiting
+Headache
+Drowsiness
Special Considerations: Use caution in pts with existing hypertension, especially with history of CHF
Should be avoided in pts with history of dystonic/extrapyramidal reactions
Onset & Duration:
Onset 1-3 min, duration 1-2 hrs.
Protocols & Dose:
D
*None in current protocols.
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MIDAZOLAM HCL
Common names:
Class:
Action:
Versed®
Benzodiazepine, anticonvulsant, sedative
Benzodiazepines act at the level of the limbic, thalamic, and hypothalamic regions of
the CNS, and can produce any level of CNS depression required. The action of these
drugs is mediated through the inhibitory neurotransmitter gamma-aminobutyric acid
(GABA). Unlike barbiturates, which augment GABA responses by increasing the
length of time that chloride channels are open, benzodiazepines enhance the effects of
GABA by increasing GABA affinity for the GABA receptor. Binding of GABA to
the site opens the chloride channel resulting in a hyperpolarized cell membrane that
prevents further excitation of the cell. Midazolam has twice the affinity for these
benzodiazepine receptors, than does diazepam.
Indications:
Seizure activity; For sedation during various emergencies; And behavioral
emergencies where the pt has aggression, violence, or agitation that creates a threat to
themselves or others.
Contraindications:
-Hypersensitivity
-Shock/Hypotension
-Acute closed-angle glaucoma
Side Effects:
+Anaphylaxis
+Respiratory depression/arrest
+Cardiac arrest
+Laryngospasm
+Bradycardia
+Significant hypotension
+Bronchospasm
+Amnesia
+Nausea/Vomiting
+Hiccups
Special Considerations: May potentiate other CNS depressants, including alcohol.
Use caution in pts with acute exacerbation of reactive/obstructive airway diseases,
due to respiratory depression.
Avoid use in pts with neuromuscular disease and late-stage Parkinson’s.
IV administration should be done slowly to diminish adverse respiratory symptoms.
Onset & Duration:
Onset 1.5-5 min, peak 20-60 min, duration 2-6 hrs.
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Protocols & Dose:
Revised April 2020
Bradycardia (AC2):
2-2.5mg IV/IO/IM/IN, Maximum 10mg
Adult Tachycardia (narrow/reg:AC6)(narrow/irreg:AC6):
2-2.5mg IV/IO, qPRN, Maximum 5mg
Adult Tachycardia (wide/reg:AC7)(wide/irreg:AC7):
2-2.5mg IV/IO, qPRN, Maximum 10mg
Pediatric Tachycardia (PC5):
0.1-0.2mg/kg IV/IO/IN, May repeat if needed, Maximum
Single Dose 2mg, Maximum Total Dose 5mg
Obstetrical Emergency (AO3):
2.5mg IV/IO, q3-5 minutes as needed 5mg IM, 2mg
IN, Maximum 10mg
Post-intubation/BIAD Management (AR8):
(Adult) 2-2.5mg IV/IO, q3-5 minutes as needed, Maximum 10mg
(Pedi) 0.1-0.2mg/kg IV/IO/IN
Crush Syndrome Trauma (TB3):
(Adult) 0.5-2mg IV/IO, 1-2mg IN, Maximum 5mg
(Pedi) 0.1-0.2mg/kg IV/IO/IM/IN, Maximum 2mg, Over 2-3 minutes as needed
Bites & Envenomations (TE1):
(Adult) 2.5mg IV/IO/IM, Over 2-3 minutes, 1-2mg IN, Maximum 5mg
(Pedi) 0.1-0.2mg/kg IV/IO/IM/IN, Maximum 2mg, over 2-3 minutes
Behavioral (UP6):
(Adult) 2.5mg IV/IO/IN, 5 mg IM
(Age ≥ 65) 1mg-2.5mg IV/IO/IN, 2.5mg IM
(Pedi) 0.1mg-0.2mg/kg IV/IO/IM/IN, q2-3 minutes as needed
Seizure (UP13):
(Adult) 2-2.5mg IV/IO/IN, 5mg IM; q3-5min, Max 10mg
(Pedi) 0.1-0.2mg/kg IV/IO/IM/IN, q3-5 minutes as needed, Maximum 10mg
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NALOXONE HCL
Common names:
Class:
Action:
Narcan®
Opioid antagonist
Naloxone competitively antagonizes opiate receptors (mu, responsible for analgesia,
euphoria, respiratory depression, and miosis; kappa, responsible for analgesia,
dysphoria, some psychomimetic effects, and sedation; and delta, responsible for
analgesia, sedation, and possibly hormonal and neurotransmitter release) thus
inhibiting both the toxic and clinical effects of opiates. It’s quick action produces
almost an immediate reversal to respiratory depression, hypotension, sedation, and
analgesia.
Indications:
Used as a reversal agent for respiratory depression secondary to suspected opioid
intoxication.
Contraindications:
-Hypersensitivity
Side Effects:
+Pulmonary edema
+Ventricular Tach/Fib
+Hypotension
+Tachycardia
+Nausea/vomiting
+Withdrawal symptoms
+Agitation
+Pain
Special Considerations: Titrate to achieve adequate respiratory drive/oxygenation, not given to restore
consciousness.
Use caution in opioid-dependent pts as naloxone use may precipitate withdrawal
symptoms.
Onset & Duration:
IV/IN route has onset 2-3 min, duration 45-90 min.
IM onset 15 min, duration 45-90 min.
Protocols & Dose:
Adult Asystole/PEA (AC1):
Cardiac Arrest (AC3):
*pearl: 2mg IM/IV/IO/IN
Pediatric Cardiac Arrest (PC4):
*pearl: 0.1mg/kg IM/IV/IO/IN
Overdose/Toxic Ingestion (TE7):
(Adult) 0.4-2mg, Max10mg, IV/IO/IM/IN/ETT
(Pedi) 0.1mg/kg, Max 2mg, IV/IO/IM/IN/ETT
Titrate to adequate ventilation and oxygenation, NOT
GIVEN TO RESTORE CONSCIOUSNESS
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NERVE AGENT KIT
Common names:
Class:
Action:
DuoDote®
Two-part antidote kit comprised of atropine and pralidoxime.
Both medications work to reverse the toxic effects of organophosphate on the body
that lead to symptoms of salivation, lacrimation, urination, diarrhea, gastric upset, and
emesis. See individual medication for information regarding specific actions.
Indications:
Organophosphate toxicity/nerve agent exposure accompanied by SLUDGE
symptoms.
Contraindications:
None in emergency situations.
Side Effects:
Consult individual medications for specific side effects.
Special Considerations: None in emergency situations.
Special Considerations: None in emergency situations.
Protocols & Dose:
WMD-Nerve Agent (TE8):
(Adult) Minor: 2 Doses Rapidly IM
Major: 3 Doses Rapidly IM
(Pedi) *pearl:
≤ 7 yrs = 1 kit
8-14 yrs = 2 kit
≥ 15 yrs = 3 kit
*Each nerve agent kit includes 2mg atropine and 600mg pralidoxime auto-injectors
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PRALIDOXIME CHLORIDE
Common names:
2-PAM®
Class:
Action:
Antidote, cholinesterase reactivator
Pralidoxime is a cholinesterase reactivator that reverses muscle paralysis after
organophosphate poisoning. Organophosphate compounds inhibit cholinesterase via
phosphorylation of the enzyme. The inhibited cholinesterase is unable to metabolize
acetylcholine resulting in an accumulation of the neurotransmitter. Acetylcholine is
present in the central nervous system, parts of the autonomic nervous system, and at
the skeletal muscle end plates; therefore, accumulation of this neurotransmitter after
organophosphate poisoning adversely affects each of these systems. In the somatic
nervous system, acetylcholine accumulation leads to paralysis. The clinical effects of
pralidoxime are most evident at skeletal neuromuscular junctions. Pralidoxime
reverses the paralysis by removing the phosphoryl group from the inhibited
cholinesterase molecule, reactivating the enzyme and restoring the body's ability to
metabolize acetylcholine, thereby decreasing blood pressure, reducing salivation,
muscle twitching, cramps, weakness, tachycardia, and facial pallor.
Indications:
Organophosphate toxicity/nerve agent exposure accompanied by SLUDGE
symptoms.
Contraindications:
-None in emergency situations
Side Effects:
+Laryngospasm
+Tachycardia
+Hypertension
+Blurred vision
+Hyperventilation
+Headache
+Nausea/vomiting
+Dizziness
+Flushing
Special Considerations: Use caution in pts with myasthenia gravis receiving anticholinesterase agents for
treatment.
Onset & Duration:
Rapid onset, peak in 10-20 min, half-life ~75 mins.
Protocols & Dose:
D
WMD-Nerve Agent (TE8):
*If nerve agent kit is unavailable, dose pralidoxime accordingly
(Adult) 600mg IV/IO/IM
(Pedi) 15-25mg/kg IV/IO/IM, Over 30 minutes
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NICARDIPINE HCL
Common names:
Class:
Action:
Cardene®
Calcium-channel blocker
Nicardipine inhibits the influx of extracellular calcium across the cell membranes of
myocardial and vascular smooth muscle without altering serum calcium
concentrations and inhibits intracellular phosphodiesterase. Unlike other calciumchannel blockers, nicardipine has greater selectivity for vascular smooth muscle than
for cardiac muscle relaxing the peripheral vasculature without affecting inotropy.
These effects elicit an increased oxygen delivery to the myocardial tissue, and a
decreased total peripheral resistance, systemic blood pressure, and afterload.
Indications:
Used for hypertension, defined as SBP ≥ 180 and/or DBP ≥ 105, that develops during
interfacility (hospital to hospital) transfer of suspected stroke pts only.
Contraindications:
-AV block
-Sick sinus syndrome
-Hypotension
-Left ventricular dysfunction
-Severe bradycardia
-Cardiogenic shock
-Hypersensitivity
Side Effects:
+AV block
+Arrhythmia
+Hypotension
+Angina
+Tachycardia
+Palpitations
+Wheezing
+Flushing
+Headache
+Nausea/vomiting
Special Considerations: Use caution in pts with history of CHF as pulmonary edema may develop
Onset & Duration:
Rapid onset with continuous effects for duration of drip, after discontinuation, effects
last ~3.
Protocols & Dose:
D
Suspected Stroke: Activase/t-PA Interfacility (AM6):
Increase 2.5mg/hr, every 5 minutes,
Titrate SBP<180mmHg, DBP<105mmHg, Maximum 15mg/hr
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NITROGLYCERIN
Common names:
Class:
Action:
Nitro Bid®, Nitrostat®, NitroMist®
Nitrate vasodilator
Nitroglycerin is converted to nitric oxide, a reactive free radical. Nitric oxide
activates the enzyme guanylate cyclase, thereby stimulating the synthesis of cyclic
guanosine 3',5'-monophosphate (cGMP). This second messenger then activates a
series of protein kinase-dependent phosphorylations in the smooth muscle cells,
eventually resulting in the dephosphorylation of the myosin light chain of the smooth
muscle fiber and the subsequent release, or extrusion, of calcium ions. The contractile
state of smooth muscle is normally maintained by a phosphorylated myosin light
chain (stimulated by an increase in calcium ions). Thus, the nitrite- or nitrate-induced
dephosphorylation of the myosin light chain signals the cell to release calcium,
thereby relaxing the smooth muscle cells and producing vasodilation.
Indications:
Chest pain thought to be cardiac in nature.
Contraindications:
-Hypersensitivity
-Head trauma
-Hypotension
-Severe brady/tachycardia
-Phosphodiesterase inhibitor (erectile disfunction medication) use in past 24-36 hrs.
Side Effects:
+Anaphylaxis
+Brady/Tachycardia
+Pulmonary edema
+Hypo/Hypertension
+Dyspnea
+Palpitations
+Headache
+Blurred vision
+Dizziness/vertigo
+Syncope
Special Considerations: Not indicated for use during pregnancy.
Use in pts with acute R sided MI may cause profound hypotension, use caution.
Onset & Duration:
SL route onset 1-3 min, duration 30 min.
Paste transdermal route onset 40-60 min, duration 18-24 hrs.
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NITROGLYCERIN SL
Protocols & Dose:
Chest Pain/STEMI (AC4):
0.3/0.4mg SL, q5 minutes as needed
*Info box: When treating suspected/confirmed MI, continue NTG even if
pt relates they are pain free and the systolic BP is manageable
CHF/Pulmonary Edema (AC5):
0.3/0.4mg SL, q5 minutes as needed
Pediatric Pulmonary Edema (PC3):
*pearl: Dose determined after consultation of Medical Control.
NITROGLYCERIN PASTE
Protocols & Dose:
Chest Pain/STEMI (AC4):
CHF/Pulmonary Edema (AC5):
SBP >100 1 inch
SBP >150 1.5 inch
SBP >200 2 inch
NITROGLYCERIN DRIP
Protocols & Dose:
D
Chest Pain/STEMI (AC4):
CHF/Pulmonary Edema (AC5):
10mcg/min, IV/IO
Increase by 10mcg/min at 10 minute intervals, keeping systolic BP > 100
**Remember to vent tubing**
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NITROUS OXIDE
Class:
Action:
Analgesic, anesthetic gas
The exact mechanism of action of nitrous oxide is unknown. Findings indicate that
the analgesic effect of N2O is opioid in nature, and, like morphine, may involve a
myriad of neuromodulators in the spinal cord. The anxiolytic effect of N2O, on the
other hand, resembles that of benzodiazepines and may be initiated at selected
subunits of the γ-aminobutyric acid type A (GABAA) receptor. Similarly, the
anesthetic effect of N2O may involve actions at GABAA receptors and possibly at Nmethyl-D-aspartate receptors as well.
Indications:
Moderate to severe pain.
Contraindications:
-Drug/Alcohol intoxication
-AMS
-History of COPD
-Pneumothorax
-Head injury
-Abd distention/pain
-Recent diving
-Suspected GI obstruction
Side Effects:
+Dizziness
+Lightheadedness
+AMS
+Hallucinations
+Nausea/Vomiting
Special Considerations: Can potentiate effects of other CNS depressants.
Administered as a 50/50 mix with oxygen
Pt self-administers ONLY through modified demand valve to reduce the occurrence
of adverse effects.
Onset & Duration:
Immediate onset, effects dissipate within 2-5 min after cessation of administration.
Protocols & Dose:
D
Pain Control (UP11):
50:50 mix if available
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NOREPINEPHRINE BITARTRATE
Common names:
Class:
Action:
Levophed®
Vasoconstrictor
Similar to epinephrine, norepinephrine has direct agonist effects on effector cells that
contain alpha- and beta-receptors. As with other catecholamines, the intracellular
action of norepinephrine is mediated via cyclic adenosine monophosphate (cAMP),
the production of which is augmented by beta stimulation and attenuated by alpha
stimulation. The primary pharmacodynamic effects of norepinephrine are cardiac
stimulation, particularly at lower doses, and vasoconstriction, which tends to
predominate with moderate to higher doses of the drug. The hemodynamic
consequences of norepinephrine's cardiovascular stimulation include increases in
systolic, diastolic, and pulse pressures. Cardiac output is generally unaffected,
although it can be decreased, and total peripheral resistance is also elevated. The
elevation in resistance and pressure result in reflex vagal activity, which slows the
heart rate and increases stroke volume. The elevation in vascular tone or resistance
reduces blood flow to the major abdominal organs as well as to skeletal muscle. As
with epinephrine, however, coronary blood flow is substantially increased secondary
to the indirect effects of alpha stimulation.
Indications:
Profound, symptomatic hypotension refractory to fluid replacement therapy,
particularly in sepsis.
Contraindications:
-Uncorrected hypovolemia
-Hypertension
Side Effects:
+Anaphylaxis
+Brady/tachycardia
+Pulmonary edema
+Hypertension
+Dyspnea
+Palpitations/PVCs
+Angina
+ST segment changes
+Vomiting
+Headache
+Diaphoresis
+Tissue necrosis
Special Considerations: Extravasation can cause tissue ischemia, necrosis, and/or gangrene.
Volume depletion should always be corrected before initiating vasopressor therapy.
Some formulations contain sulfites and should be used with caution in pts with
known hypersensitivity to sulfites.
Onset & Duration:
Rapid onset, duration is limited to 1-2 min after cessation of infusion.
Protocols & Dose:
Hypotension/Shock (AM5):
4mcg/min IV/IO, Maximum 20mcg/min, Titrate to effect
Pediatric Hypotension/Shock (PM3):
(2-12 yrs) 0.1-2mcg/kg/min IV
Start: 0.05-0.1mcg/kg/min IV, titrate to effect; max 2mcg/kg/min
Suspected Sepsis (UP15):
4mcg/minute on infusion pump to goal of MAP > 65mmHg
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ONDANSETRON
Common names:
Class:
Action:
Zofran®
Antiemetic
The process of nausea and vomiting is coordinated by the vomiting center in the
central nervous system. Stimulation can be initiated centrally in areas such as the
cerebral cortex and otic or vestibular nerves, or peripherally in areas such as the
oropharynx, mediastinum, gastrointestinal track, renal pelvis, peritoneum, or
genitalia. Centrally, ondansetron blocks the 5-hydroxytryptamine, type 3 (5-HT3)
receptor site at the chemoreceptor trigger zone, stopping the vomiting reflex produced
by the vomiting center. Peripherally, ondansetron preferentially blocks the serotonin
5-HT3 receptors at the peripheral vagal nerve terminals in the intestines, blocking the
signal transmission to the central nervous system and antagonizing the effects of
serotonin.
Indications:
Nausea and vomiting
Contraindications:
-Hypersensitivity
-Prolonged QT syndrome
Side Effects:
+Anaphylaxis
+Bronchospasm
+Brady/tachycardia
+Arrhythmia including v-fib/torsades
+AV block
+Angioedema
+Laryngospasm
+Hypotension
+Headache
+Dyspnea
+Drowsiness
+ST segment changes
Special Considerations: Use caution in pts with liver impairment.
Avoid in pts with prolonged QT as drug is known to prolong QT and may lead to
arrhythmia.
Onset & Duration:
IV route onset 5 min, peak 10 min, half-life 3-6 hrs.
ODT route onset within minutes, peak 1 hr, half-life 3-6 hrs.
Protocols & Dose:
Abdominal Pain/Vomiting & Diarrhea (UP3):
(Adult) 4-8mg IV/IO/ODT/IM
If initial dose 4mg, q15 minutes x1 if
needed
(Pedi) 4mg ODT; Max 4mg
Repeat & Max:
D
Adult max: 8mg every 8 hours, 24 mg/day max
Pediatric max: 0.15mg/kg, 16 mg/day max
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OXYGEN
Class:
Action:
Gas, oxidizing agent
The majority of oxygen molecules are carried from the lungs to the body’s tissues by
a specialized transport system, which relies on the erythrocyte. Erythrocytes contain a
metalloprotein, hemoglobin, which serves to bind oxygen molecules to the
erythrocyte. Heme is the portion of hemoglobin that contains iron, and it is heme that
binds oxygen. One hemoglobin molecule contains iron-containing heme molecules,
and because of this, each hemoglobin molecule is capable of carrying up to four
molecules of oxygen. As oxygen diffuses across the respiratory membrane from the
alveolus to the capillary, it also diffuses into the red blood cell and is bound by
hemoglobin. The following reversible chemical reaction describes the production of
the final product, oxyhemoglobin (Hb–O2), which is formed when oxygen binds to
hemoglobin. Oxyhemoglobin is a bright red-colored molecule that contributes to the
bright red color of oxygenated blood.
Indications:
Hypoxia; passive application during cardiac arrest and airway procedures; as an
adjunct for other therapies.
Contraindications:
-None in emergency situations
Side Effects:
+Vasoconstriction
Special Considerations: Oxygen should be used sparingly and titrated to 94-99% saturation to avoid adverse
effects.
Adverse effects may occur with prolonged use in pts with COPD.
Use caution in neonates, toxicity can lead to complications such as blindness and
chronic disease.
Excessive oxygen can cause vasoconstriction that may reduce cellular profusion, and
is linked to reperfusion injury secondary to free radicals.
Onset & Duration:
Absorption is highly dependent on pt’s respiratory and circulatory status.
Protocols & Dose:
Cardiac/Airway Protocols (AC1)(AC3)(AC8)(AC11)(AR3)(PC1)(PC4)(PC6):
Passive O2 @ 15L NC if available
Various other protocols:
Supplement as appropriate, titrate to saturation ≥ 90%, preferably ≥ 94%
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OXYMETAZOLINE HCL
Common names:
Class:
Action:
Afrin®
Sympathomimetic, vasoconstrictor, nasal decongestant
Oxymetazoline stimulates alpha adrenergic receptors which cause intense
vasoconstriction. When administered intranasally, this action promotes drainage and
improves ventilation.
Indications:
Active nose bleed that is unrelated to significant trauma.
Contraindications:
-Hypersensitivity
-Hypertension
-Closed-angle glaucoma
Side Effects:
+Brady/tachycardia
+Coma
+Visual impairment
+Hyper/hypotension
+Respiratory distress
+Nausea/vomiting
+Nasal irritation
Special Considerations: Use caution in pts with existing cardiovascular disease or uncontrolled hypertension.
Onset & Duration:
Immediate onset.
Protocols & Dose:
D
Epistaxis (UP9):
1 Sprays to Nostril, Followed by Direct Pressure
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OXYTOCIN
Common names:
Class:
Action:
Pitocin®
Hormone
Synthetic oxytocin elicits the same pharmacological response produced by
endogenous oxytocin, with cervical dilation, parity, and gestational age as predictors
of the dose response to oxytocin administration. Oxytocin increases the sodium
permeability of uterine myofibrils, indirectly stimulating contraction of the uterine
smooth muscle. The uterus responds to oxytocin more readily in the presence of high
estrogen concentrations and with the increased duration of pregnancy. Oxytocin
increases the amplitude and frequency of uterine contractions, which transiently
impede uterine blood flow and decrease cervical activity, causing dilation and
effacement of the cervix.
Indications:
Severe, uncontrolled, post-partum hemorrhage.
Contraindications:
-Hypersensitivity
-GI bleeding/bloody stools
-Abd pain
-Constipation/GI obstruction
Side Effects:
+Anaphylaxis
+Uterine rupture
+Arrhythmia
+Cervical laceration
+Pulmonary edema
+Nausea/vomiting
+Hypertension
+Blurred vision
+Bleeding
Special Considerations: Complications from the administration of oxytocin can lead to complete infertility or
death, and should be reserved only be when significant bleeding cannot be controlled
by other measures, posing an immediate life-threat.
It is vital to assure delivery of the baby and placenta are complete prior to
administration.
Onset & Duration:
Immediate onset, effects subsiding ~1 hr after cessation of infusion.
Protocols & Dose:
D
Childbirth/Labor (AO1):
20units IV/IO, Mix 20units in 1000mL LR, 30-60gtts/min
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PROMETHAZINE HCL
Common names:
Class:
Action:
Phenergan®
Antiemetic, antihistamine, anticholinergic.
The predominant action of promethazine is antagonism of H1-receptors. Like other
H1-antagonists, promethazine does not prevent the release of histamine, as do
cromolyn and nedocromil, but competes with free histamine for binding at H1receptor sites. Histamine receptors in the GI tract, uterus, large blood vessels, and
bronchial muscle are blocked. The relief of motion sickness and nausea/vomiting
appear to be related to central anticholinergic actions and may implicate activity on
the medullary chemoreceptor trigger zone. Other CNS receptor sites can also be
affected, since promethazine is believed to indirectly reduce stimuli to the brain stem
reticular system.
Indications:
Nausea/vomiting refractory to other antiemetic treatments, or when other antiemetics
are contraindicated.
Contraindications:
-Hypersensitivity
-History of seizures
-Hyperthermia
Side Effects:
+Anaphylaxis
+Brady/tachycardia
+Sedation/hallucinations
+Dyspnea
+Dystonia
+Injection site reaction
+Prolonged QT
+Elevated blood glucose
+Tissue necrosis
+Neuroleptic malignant syndrome
Special Considerations: May potentiate other CNS depressants and should be used with caution in pts acutely
intoxicated.
Can cause extreme irritation at the site of administration, consider diluting prior to
administering IV/IO to avoid pt discomfort.
Onset & Duration:
Onset 3-5 min, duration 4-6 hrs.
Protocols & Dose:
Abdominal Pain/Vomiting & Diarrhea (UP3):
(Adult) 12.5mg IV/IO/IM, May repeat x1 if needed
(Pedi) 6.25mg IV/IO/IM
**Dilute medication with 10mL Saline, SLOW IV PUSH**
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PROPOFOL
Common names:
Class:
Action:
Diprivan®
Nonbarbiturate anesthetic
Propofol appears to inhibit the NMDA subtype of glutamate receptors by channel
gating modulation and has agonistic activity at the GABAA receptor. Propofol
enhances the amplitude of currents evoked by subthreshold concentrations of gammaaminobutyric acid (GABA) and directly activates the GABAA receptor in the absence
of GABA. The anesthetic and amnesic properties of propofol may be wholly or partly
a result of NMDA-mediated excitatory neurotransmission depression.
Indications:
The use of propofol is limited to interfacility transfer of pts who are already intubated
and sedated for transfer by the referring facility.
Contraindications:
-Hypersensitivity
-Sulfite hypersensitivity
-Hemodynamic instability
Side Effects:
+Anaphylaxis
+Apnea
+Brady/tachycardia
+Arrhythmia including v-fib
+Bronchospasm/wheezing
+Increased ICP
+Laryngospasm
+Pulmonary edema
+Angioedema
+Hypotension
+Heart block
+ST segment changes
Special Considerations: Use caution in pts with renal compromise.
Onset & Duration:
Rapid onset ~ 30 seconds, duration of effects last 3-5 min after cessation of infusion.
Protocols & Dose:
D
Propofol:
*Sedation
25-100 mcg/kg/min
*Induction
1-2.5 mg/kg
*Maintenance
50-200 mcg/kg/min
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RANITIDINE HCL
Common names:
Class:
Action:
Zantac®
H2 antagonist
Ranitidine competitively inhibits the binding of histamine to receptors on gastric
parietal cells (designated as the H2-receptor), thus reducing basal and nocturnal
gastric acid secretion. The drug also decreases the amount of gastric acid released in
response to stimuli such as food, caffeine, insulin, betazole, or pentagastrin.
Ranitidine reduces the total volume of gastric juice, thereby indirectly decreasing
pepsin secretion.
Indications:
Mild to severe allergic reaction.
Contraindications:
-Hypersensitivity
Side Effects:
+Anaphylaxis
+Angioedema
+Bronchospasm
+Bradycardia
+Dizziness
+Headache
Special Considerations: Use caution in pts with liver or renal impairment.
Onset & Duration:
Rapid onset IV, duration of effects 8-12 hrs.
Protocols & Dose:
Allergic Reaction/Anaphylaxis (AM1):
50mg IV/IO/IM
Pediatric Allergic Reaction (PM1):
1mg/kg IV/IO/IM, Maximum 50mg
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ROCURONIUM BROMIDE
Class:
Action:
Nondepolarizing neuromuscular blocker, paralytic
Nondepolarizing agents such as rocuronium produce skeletal muscle paralysis by
competing with acetylcholine for cholinergic receptor sites at the myoneural junction.
Unlike depolarizing agents, rocuronium has little agonist activity at the motor
endplate. Skeletal muscle relaxation proceeds in predictable order, starting with
muscles associated with fine movements, e.g., eyes, face, and neck. These are
followed by muscles of the limbs, chest, and abdomen and, finally, the diaphragm.
Indications:
Airway compromise/impending compromise requiring anesthesia to secure
intubation; to reduce shivering and maintain hypothermic state during interfacility
transfer of pts who are already intubated and undergoing induced hypothermia.
Contraindications:
-Hypersensitivity
Side Effects:
+Anaphylaxis
+Apnea
+Brady/tachycardia
+Angioedema
+Bronchospasm
+Malignant hyperthermia
+Prolonged QT
+Hypo/hypertension
+Nausea/vomiting
+Flushing
Special Considerations: Only for use in pts > 12 yrs.
May exacerbate asthma symptoms.
Use caution in pts with family history of malignant hyperthermia.
Severe acid/base imbalances from various disease processes may increase the effects
of rocuronium.
Onset & Duration:
Onset 1-8 min, duration of effects dose dependent ranging 12-30 min.
Protocols & Dose:
Target Temperature Management-Interfacility (AC10):
1mg/kg IV/IO
Airway, Drug Assisted (AR3):
1.5mg/kg IV/IO
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SODIUM BICARBONATE
Class:
Action:
Electrolyte, alkalinizing agent
Immediately raises the pH of blood plasma by buffering excess hydrogen ions. This
occurs because the Na+ (sodium) and the HCO3- (bicarbonate ion) separate in
solution. While separate the negative charge on the bicarbonate is able to accept (and
will prefer over sodium) hydrogen ions. The HCO3- then becomes H2CO3 which the
body will turn into water and CO2. In tricyclic overdoses the Na+ ion is important
also in its use to attempt to overcome the sodium blockade that occurs.
Indications:
Acute abnormal EKG changes secondary to renal failure, crush syndrome, and
tricyclic antidepressant overdose; cardiac arrest of dialysis pt.
Contraindications:
-None when indicated criteria is met
Side Effects:
+Metabolic alkalosis
+Hypokalemia
Special Considerations: Administration may deactivate other medications, timing should be spaced from other
medications.
Onset & Duration:
Immediate onset, duration 1-2 hr.
Protocols & Dose:
Dialysis/Renal Failure (AM3):
50mEq IV/IO
Crush Syndrome Trauma (TB3):
(Adult) 50mEq IV/IO
(Pedi) 1mEq/kg IV/IO
Overdose/Toxic Ingestion (TE7):
(Adult) 50mEq IV/IO, q10 min as needed
(Pedi) 1mEq/kg IV/IO, q10 min as needed
Behavioral (UP6):
Police Custody (UP12):
*pearl: If pt suspected of EDS suffers cardiac arrest, consider early
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SUCCINYLCHOLINE CHLORIDE
Class:
Action:
Depolarizing neuromuscular blocker, skeletal muscle relaxant
Succinylcholine is a depolarizing skeletal muscle relaxant. It competes with
acetylcholine for the cholinergic receptors of the motor endplate, and, like
acetylcholine, it combines with these receptors to produce depolarization.
Succinylcholine, however, causes a more prolonged depolarization than acetylcholine
because it has a high affinity for the cholinergic receptor and a strong resistance to
acetylcholinesterase. Depolarization results in fasciculation of the skeletal muscles
followed by muscle paralysis. Neuromuscular transmission is inhibited as long as an
adequate concentration of succinylcholine remains at the receptor site. The paralysis
following succinylcholine administration is selective. Initially, paralysis involves the
levator muscles of the face and muscles of the glottis. Paralysis consecutively
involves the intercostals, the diaphragm, and all other skeletal muscles. Recovery of
muscles generally occurs in the reverse order.
Indications:
Airway compromise/impending compromise requiring anesthesia to secure
intubation.
Contraindications:
-Hypersensitivity
-Known neuromuscular disease
-Non-acute burns > 24 hrs
-History of malignant hyperthermia syndrome
Side Effects:
+Anaphylaxis
+Apnea
+Brady/tachycardia
+Angioedema
+Bronchospasm
+Malignant hyperthermia
+Increased ICP
+Hypo/hypertension
Special Considerations: Only for use in pts > 12 yrs.
Muscle fasciculations caused by succinylcholine may exacerbate bone fractures,
another induction agent should be considered if appropriate.
Fasciculations may also cause vomiting, compromising airway, suction equipment
should be at hand.
Severe acid/base imbalances from various disease processes may increase the effects
of succinylcholine.
Some ethnicities are more prone malignant hyperthermia, use caution in certain
populations, like those descended from the Lumbee Tribe.
Onset & Duration:
Onset < 1 min, duration 2-3 min.
Protocols & Dose:
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Airway, Drug Assisted (AR3):
2mg/kg IV/IO, May repeat x1
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TRANEXAMIC ACID
Common names:
Class:
Action:
TXA, Lysteda®, Cyklokapron®
Antifibrinolytic, hemostatic agent
Tranexamic acid is a hemostatic agent and is a synthetic derivative of the amino acid
lysine. Tranexamic acid binds to the lysine binding site for fibrin on the
plasminogen/plasmin molecule. Plasminogen has 4—5 binding sites with low affinity
for tranexamic acid and 1 high affinity binding site. The high affinity binding site is
involved with the binding of plasminogen to fibrin. Saturation of this high affinity
binding site by tranexamic acid displaces plasminogen from the surface of fibrin. This
prevents the binding of fibrin to plasmin and preserves and stabilizes the matrix
structure of fibrin and diminishes the ability of plasmin to lyse fibrin clots.
Indications:
Suspected internal hemorrhage with SBP < 90 or HR > 120, or active bleeding.
Contraindications:
-Hypersensitivity
-Active thromboembolic disease (PE, DVT, etc.)
-Suspected intercranial bleeding -Non-acute phase of injury, > 3 hrs old
Side Effects:
+Anaphylaxis
+Seizures
+Thrombi
+Headache
+Dyspnea
+Hypotension
+Pain
+Nausea/vomiting
Special Considerations: Pt’s vitals may not reflect shock when pt is taking certain cardiac medications,
contact medical control for deviation in these situations.
Onset & Duration:
Onset and peak < 30 min, half-life 2 hrs.
Protocols & Dose:
Multiple Trauma (TB6):
(Adult) 1g over 10 minutes IV/IO
(Pedi) <18yrs: 15mg/kg IV/IO; over 20min, max 1g
Epistaxis (UP9):
(Adult) Topical TXA
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