chapter 18 general pharmacology we're going to first cover the em the medications that emts can administer then we cover the thermodynamics and em medications that others may take that are outside of our scope to deliver to them so things we carry on the ambulance aspirin oral glucose oxygen activated charcoal naloxone otherwise called narcan aspirin let's talk about it first it is given to anybody that is suspected of having chest pain that is caused by myocardial infarction it is a drug that will actually reduce the clotting factors in the the blood and help solve the problems causing the myocardial infarction next one we cover oral glucose it is basically just sugar that we give to our patients patients that have some type of diabetic emergency we give them the oral glucose it brings their blood sugar back up to a level that makes it better for them to have metal normal mental status oxygen another drug we carry on the ambulance yes it is a drug you have to have medical direction or standing orders to give oxygen we pretty much function all on standing orders on oxygen so any patient that is is under our care we can give oxygen to activated charcoal comes with many different names it is charcoal that's been ground up and pulverized into a liquid form so that we can give it to our patients it absorbs poisons in the body and helps keep the body from absorbing those poisons into the bloodstream naloxone or narcan is a drug used for narcotic overdoses it binds with the cell in the receptors for the narcotics the opioid receptors so when a person has heroin or morphine or fentanyl in their system this blocks the door that gives the morphine this access to that cell if the person has not had narcotics it has no effect some of the side effects of this one though is severe drug severe vomiting after administration and also a lot of irritability if they wake up and find out you just killed their buzz so it's a one that we use a lot of caution on as an emt you can assist with medications if the patient's prescribed medication that falls into our list you can help them take the medication maybe it's uh they're not sure how to take it or they're nervous or they're not at the point where they can actually do it themselves three drugs that we are authorized to provide assistance to our patients if they've been prescribed them or metered dose inhalers nitroglycerin and epinephrine so let's talk about the bronchodilator or the metered dose inhaler typically it's albuterol the patient has been prescribed this by their doctor for asthmatic attacks if they're unsure how to take it they're not sure the dose the route everything you can think of we're there to assist them meteor dose inhalers or bronchial dilator inhalers are used mainly for patients with asthma emphysema chronic bronchitis some type of long-term lung disease these are different uh usually albuterol but they also have some that are steroids in either any direction we go with these they enlarge the breathing tubes so they can breathe better a couple of the side effects you're going to see if the patient's actually taking the meds like as directed as they will have an increased heart rate and they may be a little jittery or like they've just had a whole pot of coffee in 10 minutes another drug we have access to that if the patient has it we can give it to them is nitroglycerin it's mainly used for chest pain so you'll see it prescribed for patients what we have here on the screen is the liquid it's a spray that goes underneath the tongue it is 400 micrograms per spray if you have the tablets they're carried in a little dark colored bottle that gives them a protection from the sunlight those are 0.4 milligrams so you have to know the difference uh the liquid is 400 micrograms the tablets are 0.4 milligrams so kind of pay attention to that when we're talking about dosages here taken by patients with history of heart chest pain because of cardiac disease what it does is dilate blood vessels it's a vasodilator because it dilates every blood vessel in the body you have a little contraindications here if they have low blood pressure anything below 100 or 90 depending on your protocols you do not give it because it will drop the pressure even more you do not give it with any other vasodilators such as erectile dysfunction drugs like viagra levitra cialis any of those you want to make sure that they are not taking those medications before we give this and the side effect is exactly what we expect if you dilate all the blood vessels the blood pressure is going to drop so about five minutes after giving this you wanted to retest the blood pressure to make sure you're maintaining a good blood pressure if not you stop giving it auto injectors epinephrine auto injectors epinephrine is a drug that we use for allergic reactions severe allergic reactions called anaphylaxis they come in many different formats here we have the ones up on the screen that show you the different kinds in colorado emts with iv certification can also draw up the epinephrine into a syringe and inject the patient directly without having it prescribed in an epipen format so like we said severe allergic reactions it's a vasoconstrictor so it relaxes the smooth muscles in the airway and constricts the blood vessels around the body so we increase your blood pressure by bringing everything back to a normal size side effect very serious side effect is a increased heart rate and blood pressure we want to make sure that the patient needs it before we give it and if they give to themselves accidentally or without as having the anaphylactic reaction it will cause that heart rate blood pressure to shoot up a little bit there we do have some areas that we have force protection medications these are uh classified as uh nerve agent antidotes uh two pam is a brand name that you might see out there they're autumn epinephrine and bro or excuse me atropine is the main ingredient in these our local system we have them stored in a separate site that's secured they do not carry me the ambulance some of the bigger cities they may carry them in the ambulance but we made some decisions here at the local that they would be stored in one central location and distributed if needed information we need to be aware of about all medications we need to understand the names whether it's generic name the chemical name the trade name people call things differently so if the patient says they take acetaminophen they may also be talking about tylenol acetaminophen is the generic name tylenol is the brand name or the trade name when you're look trying to figure out if a patient needs a drug we have some major things we're going to look at the indications why do they need why why would you give the patient this drug a patient is having chest pain that's an indication for nitroglycerin contraindication why wouldn't you give it to them if they have a blood pressure below 90 or they have had cialis viagra or other vasodilating drug that's a contraindication or they're allergic to it side effects what could happen as a mild effect we know they're going to drop their blood pressure they're going to have vasodilation throughout the rest of the body that's a side effect of nitric glycerin untoward effect would be a severe drought drop of the low blood pressure or the severe headache they get so we've got indications contraindications side effects and untoward effects forms of medications things we the way we get the medications compressed powders or tablets that's the aspirin liquids that would be the epinephrine or albuterol gels would be your paste the uh glucose suspensions that is where we're gonna find uh that's the classification for charcoal it's ground up charcoal and a nice tasty uh laxative that's really sweet that's your suspension fine powders is your albuterol mist gases as oxygen and sublingual spray would be your nitroglycerin when you're giving medications it can be serious so we need to have a good no knowledge of the medication the indications the contraindications the side effects dosage how to make make sure your patient really needs it and that'll what how to watch them to make sure it's effective on the patient most recent case that's hit the news is about a two-year-old case in aurora colorado where the paramedics gave a patient 500 milligrams of a drug ketamine based on the observations of law enforcement they from the reports it sounds like they did not do an assessment on their own they relied on fire the law enforcement to say the patient needed the medication and they gave too much of it based on the patient's actual weight so being careful making sure you have all the information and you confirm everything you need to do before during and after you give a medication is the right thing to do to give a medication we have two different routes offline medication you the doctor says here's the standing orders here's our guidelines there's our protocols if you find a patient that has this medic or this symptom you can give the medication the other option is the online medical direction where you have uh contact with a physician you talk to them you explain what your patient's doing you ask for medication permission and they make a decision to help you out when your doctor tells you to give the medication say if they say go ahead and administer four 81 milligram tablets of aspirin by chewing you want to repeat that back to them okay doctor i hear you say 4 40 81 milligrams tablets of aspirin by having the patient chew them confirm it if the patient says or excuse me if the doctor says i want you to administer four cups of milk to your patient you would ask for clarification doctor did you say four cups of milk we do not carry milk on the ambulance that's not one of the drugs we mentioned so that's something to question don't be afraid to question and clarify because we don't want to make mistakes we want to make sure everybody's on the same page in our current system most of our physicians are emergency physicians and that's their sole job some of your rural communities they have doctors that work in the er as a part-time job and they have met other practices outside so they may not understand the pre-hospital limitations and get asked you to do orders that you can't give so that's when you go back and do the questioning to see if they understand what you're asking they're asking you to do every time we give a medication we're going to go through the five rights do i have the right patient if i'm giving a drug that's been prescribed to the patient is their name on the prescription should be on the bottle or somewhere that we can verify it does the patient show the right indications for this if they're not having chest pain you don't give them medications for chest pain is it the right time to administer the drug are they showing all the symptoms are they prepared for the medication have you informed them of all the the that you're going to give the medication the possible side effects verify you have the right medication don't just assume that you know what's in the box that you're handing to the patient or you're giving to the patient we've had a history in ems of using color coding on boxes for what medication we want to give the patient and sometimes those manufacturers change the color of the box make sure you know the right dose if it's a dose dependent on the patient's weight do as much as you can to get the correct weight am i giving the medication to the in the right route some drugs go in orally where you chew them and swallow them like aspirin some are sublingual like nitroglycerin they go under the tongue some are injection like an epipen you need to know the route you're administering the drug and make sure you're doing it correctly so you've got the five rights we need to make sure we're doing with every patient the routes of administration that we have available to us orally we give a patient and tell them to swallow it this is how we typically give activated charcoal oral glucose or aspirin with the aspirin we're going to ask him to chew it so that it diet it breaks down quicker in the digestive system rectally is an option for giving medications it is a paramedic level skill but as an emt you can assist with this meta any medication that can be swallowed can be administered rectally it goes in and is quickly absorbed through the digestive tract sublingual or dissolved under the tongue that's the nitroglycerin inhale to breathe into the lungs oxygen intranasal that was that little christmas tree we looked at for the narcan you spray it into the nose it absorbs through the mucosal membranes and gets into the bloodstream really quick intravenous or into the vein this is a skill that emts with iv training can use intramuscular this would be your epinephrine you give that it go sends out about an inch and a half needle into the muscle subcutaneous goes right underneath the skin if you've had your tb skin test that's where they put it is right underneath the skin it take it's a delayed response it absorbs a little bit slower intraosseous or into the bone this is another route that emt basics with iv training can administer medications and fluids as an emt you're trained to drill the needle into the bone and get provide that level of care to your patient another route is uh endotracheal paramedics can give drugs into the tracheal tube and have it absorb into the lung tissue so that's some routes you might run into as an emt you might see these things let's talk about pharma dynamics a study of effects of medications in the body if you've ever watched tv you've seen ads for drugs and the they tell you everything the drug gonna do how it's gonna miraculously kill it cure everything you've got and then it tells you the list of mandatory side effects that they want to tell you what's going on so we want to understand how the drug works in the body so we don't have those side effects and how we and so we can watch for the mild effects and stop before we have serious effects some some things about our patients change how the drug works on them maybe they have kidney disease or liver disease and the body doesn't absorb things as quick as possible or it won't absorb the medication at all because of other medications they're taking so we need to understand how medications work together and against each other and how they work with the different cons conditions a patient may have when you give a medication you document who told you to give the medication or why you gave it what route you gave it how much you gave and what the reaction to the pain the medication the patient had so document everything document if you make a mistake if you try to hide a mistake that's a lot worse than coming clean up front saying doc i gave the wrong med but this is what i did to help fix it i would definitely call medical control before you do anything to fix it to make sure we're on the right path but fixing problems is much better than hiding problems this one you might see on a patient that has some type of respiratory problem it's a daily use respiratory inhaler it gives them a dose of the medication they need to keep their airways clear a lot of our patients are on routine meds if you see if you understand the basic meds and understand what they might be taking them for it helps you understand a history of your patient a little bit quicker some of the herbs the patients take all different options here this is the table in your book everybody thinks they have a new disease or a new herbal supplement to cure the problems so pay attention to what they tell you know the different ones out there and then if you're not sure ask the patient why they take it they usually know so let's talk about iv therapy as an emt basic you cannot start ivs you need to go to the iv training class which we have here at uc health you have to be in the colorado emt before you can get in because we have to have you cleared to do clinicals but well even before then you can help with setting up ivs so we're going to talk a little bit about this an iv is a way to get fluids in or medications into the body quickly the first one first basic uh the very basic option we have is a saline lock or a heparin lock we put a catheter into the vein we put a cap on it and we put either saline to keep a clot from forming or heparin which is an anti-clot medication and that gives a support to give medications anytime we need to what you see a lot on patients that are more critical or iv bags they have to have the same type of catheter put into the patient and we typically put the uh saline lock in and then hook this bag to that saline lock just so we have a way to change things out if we need to so important things with the iv bag is make sure it's above the butt patient if you put it below the blood draws drains back into the bag so we want to keep it above so that we have gravity feeding into the body you have the clear plastic tubing that connects everything from the catheter to the bag that clear plastic tubing it's important things the drip chamber this is where we can measure how much fluid is going into the body we have two different sizes we primarily use in ems one is it's called a micro drip so every drip is 1 60 of a milliliter so 60 drops makes one milliliter the other one is one tenth of a milliliter so every 10 drops makes a milligram so it helps us get we count the number of drops so we can tell how much is going to change the flow we have a regulator that goes up and down on the side that we can adjust how much fluid is moving through and then we also have ports on the side that if we need to give medication we don't have to take it out of your patient you just add it to the the the iv fluid it shows the pa the emt checking the bag to make sure it's within the expiration date and it's clear it has to be all of the medications we give for all the iv fluids we use pre-hospital or clear so you should be able to see through them and they need to be within the expiration date this is a spike that goes in the bottom of the bag what's under the the thumb is the drip chamber that's where it drips in you can see the flow control that's in the package it's got the little roller uh that goes up and down and you move that to change how much flow is going through this is putting the spike in the bag typically we do it upside down so if it leaks you don't get it covered in fluid but that's okay a little bit better picture of the drip chamber you can see how big that the drip part of it is underneath the white top that is a 10 ml or 10 drop set and then you'll see the drops dripping into the chamber here and then it goes to the tube and this is your adjustment port you can roll it up to make it go faster roll it down to make it go slower this is adjusting the flow to maintain the iv this is where emts will save your paramedics if there ha if the it's you don't see a drip in the chamber make sure they know that the iv is not flowing and here's the things you want to check did you forget to turn it back on did you close a clamp on the tubing there's some clamps throughout the tubing did somebody's kink the tube did you park the ambulance cot on the tubing maybe it's caught underneath the patient and twisted around did you take the constricting band off used to start the iv did you put a tourniquet on that arm or are you taking a blood pressure on that arm are you impeding the flow of blood somehow then every so often you want to look at the site to make sure that they're not bleeding anywhere or that they're not having any swelling or redness or the skin's getting warm around the injection site that's a sign of infection or infiltration all bad things that we need to address with the iv certified person so as always if you have questions feel free to bring them to class and let's chat thanks