Tap any sentence or table row to start listening from there. Education only — local protocols and medical direction override.
Prehospital Drug Study Sheet — Chapter 13 Principles of Pharmacology
Prepared for Chase Westbrook • NREMT-Paramedic review • Based on Jones & Bartlett Paramedic, Ch 13 (pp 725–794)
Disclaimer: Education only. Local protocols and medical direction override everything here; any doses shown are typical adult teaching doses, not standing orders.
How to read this sheet: "p ###" = the chapter page where the drug is discussed. Doses: Ch 13 is a principles chapter and gives very few doses (it points to Ch 15, Emergency Medications). Doses below are standard, widely taught adult values (mostly AHA ACLS 2020 / common NREMT teaching) and are marked "per protocol" wherever practice varies. "(ch)" = stated in Chapter 13; "(standard)" = standard teaching content added for completeness. Page refs come from the printed page markers in the e-book text (may be off by ±1). Verify with Ch 15, your drug reference, and local protocol.
1. Receptor Primer (Table 13-10, pp 735–737, 758–761)
Agonist = binds a receptor and turns the cell ON (the right key turns the ignition). Antagonist = sits in the receptor and blocks the agonist ("Ha, ha, I got here first"). Competitive antagonists (naloxone, atropine) can be out-competed by more agonist — effect depends on concentration. Noncompetitive antagonists bind permanently (aspirin on platelet COX → effect up to 10 days; ketamine on NMDA). Partial agonist = binds but only partially activates, with a ceiling effect (buprenorphine on mu receptors, p 736).
| Receptor | Agonist (stimulation) effect | Agonists / stimulators | Antagonists / blockers |
|---|---|---|---|
| Alpha-1 (α1) | Constricts peripheral arteries/arterioles (vasoconstriction ↑BP); contracts bladder & GI sphincters | Phenylephrine (pure α), norepinephrine (mostly α), epinephrine (high dose) | Prazosin; labetalol (some α1); phentolamine (reverses vasopressor extravasation) |
| Alpha-2 (α2) | Suppresses norepinephrine release; inhibits insulin & pancreatic enzyme release; ↓GI motility | Clonidine, methyldopa (central α2 agonists → ↓sympathetic tone → vasodilation) | Nonselective α-blockade of α2 → reflex tachycardia |
| Beta-1 (β1) — "one heart" | ↑ heart rate (chronotropy), ↑ contractility (inotropy), ↑ conduction (dromotropy); renin release | Epinephrine, dobutamine, dopamine, norepinephrine (some), isoproterenol | Beta blockers (metoprolol, propranolol, labetalol, sotalol) → ↓HR, ↓BP |
| Beta-2 (β2) — "two lungs" | Bronchodilation; dilates arterioles of heart, lungs, skeletal muscle; ↑glucagon; relaxes intestine, bladder, uterus | Albuterol, levalbuterol, salmeterol, formoterol; epinephrine; isoproterenol | Nonselective beta blockers (propranolol) → bronchospasm risk in asthma/COPD |
| Dopaminergic (D1–D5) | Brain functions (D1–D5); D1 regulates renal function/renin | Dopamine | Phenothiazines (antiemetic/antipsychotic action via dopamine receptors in brain) |
| Muscarinic (M1–M5) — parasympathetic | M2 (heart): ↓HR & contractility (vagus/ACh). M3: gland secretion, smooth-muscle contraction (salivation, bronchoconstriction, secretions, GI) | ACh (vagal tone); organophosphates/nerve agents cause excess ACh | Atropine (competitive), ipratropium (antimuscarinic bronchodilator), diphenhydramine (side effect) |
| Nicotinic | ACh at the neuromuscular junction → skeletal muscle contraction | Succinylcholine (depolarizes first → fasciculations) | Rocuronium, vecuronium (nondepolarizing). Atropine does NOT block nicotinic → won't fix weakness/fasciculations in organophosphate poisoning |
| Opioid (mu, delta, kappa) | Mu: analgesia, sedation, euphoria, pinpoint pupils, respiratory depression, ↓GI motility | Morphine, fentanyl, hydromorphone, meperidine | Naloxone (competitive); buprenorphine = partial agonist |
Sympathomimetic spectrum (p 760): pure α phenylephrine → mostly α norepinephrine → mixed epinephrine (β at low dose, α predominates at high dose) → pure β isoproterenol. Beta agents: ↑rate/force/automaticity, bronchodilate, dilate arteries. Alpha agents: no direct heart effect, slight bronchoconstriction, marked vasoconstriction. Know the receptor and you can predict the indication (p 761).
2. Medications Used in Airway Management (RSI / medication-facilitated airway) — pp 765–767
| Drug (generic, brand) • page | Class / type | What it does (plain language) | What it treats (indications) | Key contraindications / cautions | Typical adult teaching dose / route |
|---|---|---|---|---|---|
| Etomidate (Amidate) • p 765 | Sedative-hypnotic (ultra-short-acting) | Single-dose profound sedation; minimal effect on BP/hemodynamics (ch) | Induction for intubation / airway placement | Short duration → patient must be promptly re-sedated after airway placed (ch). Myoclonus; adrenal suppression (standard) | 0.3 mg/kg IV (standard RSI teaching); per protocol |
| Ketamine (Ketalar) • pp 736, 765 | Dissociative anesthetic; noncompetitive NMDA antagonist; PCP-like | Profound dissociation/general anesthesia; maintains BP & HR; some bronchodilation (ch). Effects ~10–15 min (ch) | Airway placement (good for asthma/COPD respiratory failure); some systems: refractory pain, delirium (ch) | Chapter: raises ICP → less optimal in head injury. Emergence reactions, hypersalivation, laryngospasm (standard) | Induction 1–2 mg/kg IV (standard); analgesia/sedation doses per protocol |
| Midazolam (Versed), Diazepam (Valium), Lorazepam (Ativan) • pp 765–766 | Benzodiazepines (-am stem) | Potent antiseizure, anxiolytic, sedative effects (enhance GABA — standard) | Status/active seizures (IV, IM, IN, rectal); post-intubation maintenance sedation; anxiety (where allowed) | Hypotension at high doses (ch) — poor primary induction agent in shock/trauma; respiratory depression; synergism with opioids (p 745); pregnancy: class D, life-threats only (ch) | Seizure (standard): midazolam 10 mg IM (>40 kg) or lorazepam 0.1 mg/kg IV (max 4 mg) or diazepam per protocol |
| Succinylcholine (Anectine) • p 766 | Depolarizing neuromuscular blocker (paralytic) | Binds nicotinic receptors → brief activation (fasciculations) → then blocks ACh. Onset <60 s, duration 4–6 min (ch) | Paralysis for intubation | Malignant hyperthermia (ch) — screen for personal/family anesthesia reaction. Hyperkalemia risk (burns/crush >24 h, neuromuscular disease, renal failure — standard). No sedation/analgesia — sedate first | 1.5 mg/kg IV (standard); per protocol |
| Rocuronium (Zemuron) • p 767 | Nondepolarizing neuromuscular blocker | Occupies (doesn't activate) nicotinic receptors. Fastest onset of the class; duration 30–60 min (ch) | Paralysis for emergency airway placement; ventilator synchrony | Only if you can oxygenate/ventilate and have rescue airway (ch). No sedation — must sedate | 1–1.2 mg/kg IV (standard); per protocol |
| Vecuronium (Norcuron) • p 767 | Nondepolarizing neuromuscular blocker | Same as rocuronium; duration 20–35 min (ch) | Adjunct or sole paralytic for airway procedures | Same paralytic cautions — immediate threat to life if airway can't be secured (ch) | 0.1 mg/kg IV (standard); per protocol |
| Phenylephrine (Neo-Synephrine) • pp 759, 773 | Synthetic, almost pure alpha-1 agonist | Vasoconstricts mucosa (shrinks nasal tissue, less bleeding) | Mucosal vasoconstrictor during artificial airway placement (e.g., nasal intubation) (ch) | Hypertension, reflex bradycardia (standard) | Topical/intranasal per protocol |
3. Respiratory Medications — pp 767–768
| Drug (generic, brand) • page | Class / type | What it does (plain language) | What it treats (indications) | Key contraindications / cautions | Typical adult teaching dose / route |
|---|---|---|---|---|---|
| Albuterol (Ventolin, Proventil) • pp 760, 767 | Selective beta-2 agonist bronchodilator (-terol) | Relaxes bronchial smooth muscle → bronchodilation; shifts K⁺ into cells (ch) | Acute bronchospasm (asthma, COPD, allergic reaction); temporary treatment of hyperkalemia (ch) | Some beta-1 effect → tachycardia, tremor; monitor cardiac effects (ch) | 2.5 mg nebulized (or MDI per protocol); repeat per protocol |
| Levalbuterol (Xopenex) • pp 760, 767 | Selective beta-2 agonist | Like albuterol, with fewer reported beta-1 effects (ch) | Bronchospasm | Tachycardia less common but possible | Per protocol (nebulized) |
| Salmeterol, Formoterol • p 760 | Long-acting beta-2 agonists (home meds) | Maintenance bronchodilation | Long-term asthma/COPD control | Not rescue drugs — patient still needs short-acting beta-2 (standard) | Home med — N/A |
| Ipratropium bromide (Atrovent) • p 767 | Anticholinergic / short-acting antimuscarinic bronchodilator | Blocks muscarinic receptors → bronchodilation and less mucus; poor systemic absorption = few cardiac effects (ch) | Add-on to beta agonist for bronchospasm/reactive airway disease, COPD (ch) | Dry mouth; caution glaucoma, peanut/soy allergy with some MDIs (standard) | 0.5 mg nebulized, usually with albuterol |
| Methylprednisolone (Solu-Medrol), Dexamethasone (Decadron), Prednisone • p 767 | Corticosteroids (-sone/-olone) | Reduce airway inflammation → improve oxygenation/ventilation (ch); immunosuppressant (ch) | Asthma, COPD, allergic reactions, airway inflammation/upper-airway edema (ch) | Many contraindications/adverse effects; endocrine effects; ↑glucose (ch/standard). Slow onset (hours) — not a substitute for bronchodilators/epi | Methylprednisolone 125 mg IV (standard); dexamethasone/prednisone per protocol |
| Montelukast (Singulair), Zafirlukast (Accolate) • p 768 | Leukotriene receptor antagonists (-lukast) | Block leukotrienes (bronchoconstriction, inflammation, mucus) (ch) | Long-term asthma & allergy control (ch) | Not for acute bronchospasm (ch) | Home med — N/A |
| Epinephrine (nebulized/IM) • p 772 | See Cardiovascular (catecholamine) | Alpha vasoconstriction ↓ airway edema; beta-2 bronchodilation | Upper-airway edema (ch: vasoconstrictor), croup, anaphylaxis, severe asthma | See epinephrine row | Per protocol |
| Magnesium sulfate • pp 785–786 | Electrolyte (see Misc) | Relaxes bronchial smooth muscle (ch) | Adjunct for severe, refractory asthma (ch) | Hypotension, respiratory depression, loss of DTRs (ch) | 2 g IV over 10–20 min (standard) |
4. Cardiovascular — Antidysrhythmics (Vaughan-Williams classes) — pp 768–770
Cardiac action potential (p 768–769): Phase 4 rest (diastole) → Phase 0 rapid Na⁺ in (depolarization) → 1 → 2 (plateau, Ca²⁺ in) → 3 (K⁺ out, repolarization). Class I = Na⁺ channel blockers • Class II = beta blockers • Class III = K⁺ channel/prolong repolarization (↑ refractory period) • Class IV = Ca²⁺ channel blockers • Adenosine = "unclassified".
| Drug (generic, brand) • page | Class / type | What it does (plain language) | What it treats (indications) | Key contraindications / cautions | Typical adult teaching dose / route |
|---|---|---|---|---|---|
| Procainamide (Pronestyl) • p 769 | Class IA antidysrhythmic (Na⁺ channel blocker) | Suppresses ectopic foci; slows conduction (ch) | Variety of atrial and ventricular dysrhythmias (ch); stable wide-complex tachycardia (standard) | Prolongs QRS and QT (ch); hypotension; avoid in long QT/heart failure (standard) | 20–50 mg/min IV until stop criteria, max 17 mg/kg (AHA standard); per protocol |
| Lidocaine (Xylocaine) • p 769 | Class IB antidysrhythmic; local anesthetic | Blocks Na⁺ channels in Purkinje fibers/ventricles; suppresses ectopy (ch) | Ventricular dysrhythmias (VF/pVT, VT); local anesthesia; adjunct to blunt ↑ICP during intubation (ch) | Many drug interactions; caution liver or kidney disease (ch). Toxicity: CNS (confusion, seizures — standard) | Arrest: 1–1.5 mg/kg IV/IO, then 0.5–0.75 mg/kg (AHA) |
| Metoprolol (Lopressor), Propranolol (Inderal) • pp 760, 769 | Class II — beta blockers (-olol); metoprolol β1-selective, propranolol nonselective | Competitively block catecholamines at beta receptors → ↓HR, contractility, conduction (ch) | Rate control, hypertension, angina, post-MI (ch/standard) | Reactive airway disease (bronchospasm, esp. nonselective); with CCBs → conduction block/hypotension (ch). Toxicity: brady, hypotension, blocks → glucagon antidote (p 785) | Per protocol |
| Amiodarone (Cordarone, Nexterone) • pp 769–770 | Class III antidysrhythmic | Prolongs action potential and refractory period (ch) | Atrial and ventricular dysrhythmias (ch): VF/pVT, stable VT, AF rate control | Hypotension, bradycardia, QT prolongation (standard); pulmonary toxicity in up to 10.7% on long-term oral use (ch) | Arrest: 300 mg IV/IO, then 150 mg. Stable VT: 150 mg over 10 min (AHA) |
| Sotalol (Betapace) • p 770 | Class III (also beta-blocking) | Prolongs repolarization | Oral for atrial/ventricular dysrhythmias; IV can terminate VT (ch) | QT prolongation/torsades, bradycardia (standard) | Home med / per protocol |
| Diltiazem (Cardizem), Verapamil (Calan) • p 770 | Class IV — calcium channel blockers (non-dihydropyridine) | Slow AV-node conduction, ↓ectopic automaticity, relax vascular smooth muscle (ch) | Rate control: stable narrow-QRS tachycardia; AF/flutter without pre-excitation (ch); also HTN, angina, migraine, preterm labor (ch) | WPW/pre-excitation, hypotension, heart failure, wide-complex tachycardia (standard). Give over ≥2 min with ECG/BP monitoring (ch). Diltiazem less BP drop (ch). With beta blockers → block/hypotension | Diltiazem 0.25 mg/kg IV over 2 min; verapamil 2.5–5 mg IV over 2 min (standard) |
| Adenosine (Adenocard) • p 770 | Unclassified antidysrhythmic | Briefly blocks AV node; half-life <10 s; causes 5–15 s pause (ch) | Stable regular narrow-QRS tachycardia (SVT/AVNRT); diagnostic aid (ch) | 2nd/3rd-degree block, sick sinus; caution asthma; not for irregular/pre-excited AF (standard). Run a continuous ECG strip (ch) | 6 mg rapid IV push + flush, then 12 mg (AHA) |
| Atropine sulfate • pp 771–772 | Anticholinergic — competitive muscarinic antagonist | Blocks vagal ACh at M2 → ↑HR; dries secretions (ch) | Symptomatic bradycardia (vagal); pre-airway in children; organophosphate/nerve agent antidote (ch) | Unlikely to work in 2nd-degree type II/3rd-degree AV block (ch); does not reverse nicotinic effects (weakness, fasciculations) (ch) | Brady: 1 mg IV q3–5 min, max 3 mg (AHA 2020). Organophosphate: repeat until secretions dry — no max (ch) |
5. Cardiovascular — Pressors, Vasodilators, BP & Heart-Failure Drugs — pp 770–776
| Drug (generic, brand) • page | Class / type | What it does (plain language) | What it treats (indications) | Key contraindications / cautions | Typical adult teaching dose / route |
|---|---|---|---|---|---|
| Epinephrine (Adrenalin) • pp 760, 772 | Catecholamine — α, β1, β2 agonist | ↑HR & contractility, vasoconstricts (α), bronchodilates (β2); β at low dose, α predominates at high dose (ch) | Cardiac arrest, anaphylaxis, severe asthma, croup, symptomatic bradycardia, shock | ↑ myocardial O₂ demand — extreme caution with myocardial ischemia, cardiomyopathy, cardiogenic shock (ch). Know your concentration (1 mg/mL vs 0.1 mg/mL) | Arrest: 1 mg (0.1 mg/mL) IV/IO q3–5 min. Anaphylaxis: 0.3–0.5 mg IM (1 mg/mL) (standard) |
| Norepinephrine (Levophed) • pp 760, 773 | Catecholamine — mostly α, some β1 | Strong vasoconstriction > cardiac effects (ch) | Loss of vasomotor tone: septic, neurogenic, anaphylactic shock (ch) | Extravasation → tissue necrosis (treat with phentolamine); central line preferred; reassess IV site (ch) | Continuous IV infusion, titrated (ch) — per protocol |
| Dopamine (Intropin) • p 773 | Catecholamine — dose-dependent dopaminergic/β/α | Effects change with dose (ch) | Hypotension refractory to fluids (ch); symptomatic bradycardia (AHA) | Tachydysrhythmias; extravasation; must use pump (ch) | 2–20 mcg/kg/min IV infusion (standard) |
| Dobutamine (Dobutrex) • p 773 | Synthetic catecholamine — mainly β1 | Big ↑contractility, slight ↑HR (ch) | Cardiogenic shock/heart failure, often with a vasodilator (ch) | Tachycardia, dysrhythmia; pump + close monitoring (ch) | Infusion per protocol (critical care) |
| Milrinone (Primacor) • p 773 | Inotrope-vasodilator (PDE-3 inhibitor) | ↑contractility + dilates arteries & veins (ch) | Heart failure (ch) | Long-term use ↑ mortality (ch); hypotension | Per protocol (CCT) |
| Isoproterenol (Isuprel) • p 759 | Pure beta agonist (sympathomimetic) | Stimulates heart, dilates bronchi and arteries (ch) | Bradycardia refractory to atropine (standard, critical care) | Tachydysrhythmias, ↑ O₂ demand | Per protocol |
| Nitroglycerin (Nitrostat, Nitro-Bid) • pp 751, 774 | Nitrate — direct vasodilator / antianginal | Mainly dilates veins and coronary arteries → ↓preload, ↓O₂ demand, ↑coronary flow (ch) | Chest pain/ACS, angina, hypertensive pulmonary edema/CHF | PDE-5 inhibitors (sildenafil, tadalafil) → severe refractory hypotension (ch); right-ventricular MI (get 15-lead) (ch); hypotension. Store tabs in closed light-protected glass; binds plastic (ch) | 0.4 mg SL q5 min, up to 3 doses if BP allows (standard) |
| Sodium nitroprusside (Nipride) • p 774 | Potent IV direct vasodilator (arteries + veins) | Rapid, titratable BP reduction (ch) | Malignant HTN, cardiogenic shock (with inotrope), unstable aneurysm (ch) | Metabolized to cyanide/thiocyanate — toxicity with prolonged infusion (ch) | Infusion per protocol (CCT) |
| Hydralazine (Apresoline) • pp 774–776 | Direct arteriolar vasodilator | Dilates arterioles → ↓SVR (ch) | Pregnancy-induced hypertension (ch); HF (with isosorbide dinitrate) | Reflex tachycardia, hypotension (standard) | Per protocol |
| Isosorbide dinitrate (Isordil), mononitrate (Imdur) • p 776 | Long-acting nitrates | Vasodilation (like nitro) | Angina prevention; HF (dinitrate + hydralazine) (ch) | Same PDE-5 inhibitor warning (standard) | Home med — N/A |
| Epoprostenol (Flolan) • p 774 | Prostacyclin vasodilator; antiplatelet | Dilates pulmonary/systemic vessels; inhibits platelet aggregation (ch) | Pulmonary arterial hypertension — continuous home infusion (ch) | Never let infusion stop — fix IV access/pump; contact medical control; tachycardia, flushing, bleeding (ch) | Patient's own infusion — per medical control |
| Labetalol (Trandate, Normodyne) • p 771 | Mixed α1 + β1/β2 blocker (IV mainly beta) | Lowers BP | Hypertensive emergency (ch) | Cocaine or pheochromocytoma → give an alpha blocker first (unopposed alpha) (ch); asthma, bradycardia, heart block (standard) | Per protocol |
| Clonidine (Catapres), Methyldopa (Aldomet) • pp 771, 776 | Central alpha-2 agonists | ↓ norepinephrine release → vasodilation (ch) | Hypertension (clonidine PO for emergency HTN) (ch) | Sedation, bradycardia, rebound HTN if stopped (standard) | Per protocol / home med |
| Phentolamine (Regitine) • p 771 | Alpha blocker | Reverses local vasoconstriction (ch) | Extravasation of norepinephrine/vasopressors — injected SubQ into site (ch) | Hypotension, tachycardia (standard) | Per protocol |
| Prazosin (Minipress) • p 776 | Alpha-1 blocker (-azosin) | Blocks α → vasodilation, ↓BP (esp. diastolic) (ch) | Hypertension, enlarged prostate (ch) | Orthostatic hypotension, reflex tachycardia (ch) | Home med — N/A |
| Enalapril (Vasotec), Lisinopril, Captopril, etc. • pp 771, 776 | ACE inhibitors (-pril) | Block angiotensin I → II → ↓BP & afterload, no reflex tachycardia (ch) | HTN, cardiomyopathy, heart failure; kidney protection (ch) | Dry cough; angioedema — responds poorly to epi/antihistamines → difficult airway (ch); pregnancy, hyperkalemia (standard) | Home med; enalapril IV per protocol |
| Losartan (Cozaar), Valsartan (Diovan), etc. • p 776 | Angiotensin II receptor blockers (-sartan) | Block angiotensin II receptor → ↓BP | HTN, heart failure | Hypotension, hyperkalemia; pregnancy (standard) | Home med — N/A |
| Digoxin (Lanoxin) • p 773 | Digitalis (cardiac glycoside) | ↑ force of contraction; slows AV conduction → slower rate in AF/flutter (ch) | Chronic heart failure; rapid AF/flutter/SVT (ch) | Toxicity: anorexia, N/V, headache, blurred/yellow vision, almost any dysrhythmia (ch). Sensitive to low K⁺ and to calcium (ch). Antidote: digoxin-specific antibodies (Digifab) (p 747) | Home med — N/A |
| Furosemide (Lasix) • pp 730, 775 | Loop diuretic (also bumetanide, torsemide) | Blocks Na⁺ reabsorption in loop of Henle → diuresis (ch) | Pulmonary edema/volume overload, heart failure, HTN (ch) | Hemodynamic instability, electrolyte disturbances (ch) — ↓K⁺; dehydration; sulfa allergy caution (standard) | 0.5–1 mg/kg (commonly 40 mg) slow IV (standard); per protocol |
| Mannitol (Osmitrol) • pp 736, 775 | Osmotic diuretic | Pulls water out of brain/eyes; keeps urine flowing (ch) | ↑ICP/cerebral edema (critical care) (ch) | Electrolyte shifts; prolonged use → paradoxical ↑ICP (ch) | Per protocol (CCT) |
| Hydrochlorothiazide, Chlorothiazide (Diuril), Metolazone; Spironolactone (Aldactone), Triamterene • p 775 | Thiazide diuretics; potassium-sparing diuretics | Thiazide: block Na⁺ in distal tubule. K-sparing: block Na⁺ in collecting tubule (ch) | HTN, edema, heart failure | Thiazides ↓K⁺; K-sparing → ↑K⁺ (standard) | Home meds — N/A |
| Atorvastatin (Lipitor), Simvastatin (Zocor), etc. • p 776 | Statins (cholesterol-lowering, -statin) | Lower cholesterol (standard: block HMG-CoA reductase) | Prevent heart disease | Muscle pain/rhabdomyolysis (standard) | Home med — N/A |
6. Blood (Hematologic) — Clotting Drugs & Blood Products — pp 776–781
| Drug (generic, brand) • page | Class / type | What it does (plain language) | What it treats (indications) | Key contraindications / cautions | Typical adult teaching dose / route |
|---|---|---|---|---|---|
| Aspirin (ASA) • pp 736, 780 | Antiplatelet (NSAID); noncompetitive COX antagonist | Blocks platelet aggregation; effect lasts until platelets replaced (up to 10 days) (ch) | ACS/chest pain; ischemic stroke once hemorrhage ruled out (ch) | True allergy — ask details (GI upset ≠ allergy) (ch); active GI bleed, hemorrhagic stroke; bleeding | 162–325 mg chewed (non-enteric; often 4 × 81 mg) (standard) |
| Clopidogrel (Plavix), Prasugrel (Effient), Ticlopidine (Ticlid) • p 780 | Antiplatelet (-grel), P2Y12 type | Inhibit platelet aggregation by a different path than aspirin (ch) | Aspirin alternative; ACS, stents, stroke prevention (ch) | Bleeding; ticlopidine has serious adverse effects (ch) | Per protocol / home med |
| Abciximab (ReoPro), Eptifibatide (Integrilin), Tirofiban (Aggrastat) • p 780 | Glycoprotein IIb/IIIa inhibitors (IV) | Potent platelet inhibition (ch) | ACS during interfacility transport (ch) | Bleeding & thrombocytopenia in ~5–7% (ch) | Infusion per sending facility |
| Heparin, Enoxaparin (Lovenox), Fondaparinux (Arixtra) • p 779 | Anticoagulants (-parin / -parinux) | Enhance antithrombin III → stop new clots forming/growing; do not dissolve clots (ch) | ACS, DVT, PE; fondaparinux also post-STEMI (ch) | Bleeding, thrombocytopenia (ch) | Per physician / protocol |
| Warfarin (Coumadin) • pp 779–780 | Coumarin anticoagulant (vitamin K antagonist) | Blocks production of 4 vitamin K–dependent clotting factors (ch) | Prevent/treat clots (AF, valves, DVT/PE) (ch) | Life-threatening bleeding (esp. trauma); many food/drug/alcohol interactions (ch). Report PT/INR at handoff (ch). Reversal: vitamin K, FFP/factors (standard) | Home med — N/A |
| Rivaroxaban (Xarelto), Apixaban (Eliquis), Edoxaban (Savaysa); Dabigatran (Pradaxa) • p 780 | Factor Xa inhibitors (-xaban); direct thrombin inhibitor (-gatran) | Block clotting cascade directly | Prevent stroke in AF; DVT/PE | Bleeding risk in trauma/head injury — always ask about "blood thinners" | Home meds — N/A |
| Alteplase / tPA (Activase) • pp 780–781 | Fibrinolytic (-plase) | Dissolves clots in arteries and veins (ch) | Acute MI (where PCI not available), acute ischemic stroke; occluded catheters (ch) | Life-threatening hemorrhage; recent trauma/surgery and many other contraindications (ch). Time-critical — note onset time, avoid extra IV sticks, don't delay transport (ch) | Physician-directed |
| Tranexamic acid (TXA; Cyklokapron/Lysteda) • p 779 | Antifibrinolytic (lysine analog) | Prevents breakdown of fibrin clots (stops hyperfibrinolysis) (ch) | Severe traumatic hemorrhage (ch); also PPH (standard) | Give within 3 h of injury — later ↑ complications (ch); thromboembolic history (standard) | 1 g IV over 10 min (standard); per protocol |
| Blood products: PRBCs, LTOWB, FFP/liquid plasma, cryoprecipitate, platelets • pp 776–779 | Blood components | PRBCs ↑O₂ carrying (1 U ≈ +3% Hct); plasma/cryo replace clotting factors; platelets fix thrombocytopenia (ch) | Hemorrhagic shock, anemia, coagulopathy, warfarin toxicity, DIC (ch) | Transfusion reactions (monitor temp, BP, urine color); citrate → hypocalcemia; old blood → hyperkalemia; only NS in Y-site; filtered tubing (ch). Unmatched = O-negative (ch) | PRBC ≤4 h/unit; rapid via pressure infuser in critical pts (ch) |
7. Neurologic — Pain, Opioid Reversal, Seizures — pp 781–782
| Drug (generic, brand) • page | Class / type | What it does (plain language) | What it treats (indications) | Key contraindications / cautions | Typical adult teaching dose / route |
|---|---|---|---|---|---|
| Morphine sulfate • p 782 | Opioid agonist (mu); Schedule II | Activates mu receptors → analgesia, euphoria, sedation (ch) | Moderate–severe pain; ACS pain per protocol | Respiratory depression, hypotension, bradycardia; N/V in up to 60% (aspiration risk); histamine release (itching, flushing — not true allergy) (ch) | Per protocol (small IV increments, titrated) |
| Fentanyl (Sublimaze) • p 782 | Synthetic opioid agonist; Schedule II | Potent analgesia; less hypotension, less nausea/histamine than morphine (ch) | Preferred analgesic in critical/unstable patients; IV, IM, intranasal (ch) | Respiratory depression; synergism with benzos (p 745); chest-wall rigidity with rapid high doses (standard) | 1 mcg/kg IV/IN (standard); per protocol |
| Hydromorphone (Dilaudid), Meperidine (Demerol) • p 782 | Opioid agonists | Analgesia | Pain (selected EMS/CCT) (ch) | Same opioid cautions; meperidine → seizures/serotonin issues (standard) | Per protocol |
| Buprenorphine (Buprenex, Subutex) • p 736 | Partial mu agonist | Ceiling effect; blocks other opioids (ch) | Analgesia; opioid addiction treatment (ch) | Blunts response to other opioids; hard to reverse (standard) | Home med / per protocol |
| Naloxone (Narcan) • pp 735, 782 | Competitive opioid antagonist | Displaces opioids from receptors → reverses respiratory depression (ch) | Opioid overdose with respiratory depression (ch) | Ventilate first. Shorter duration than many opioids → re-sedation; large/repeat doses for potent opioids; in dependent pts give only enough to restore breathing → avoids severe withdrawal (ch) | 0.4–2 mg IV/IM/IN (IN device 4 mg); titrate to breathing (standard) |
| Phenytoin (Dilantin), Fosphenytoin (Cerebyx) • p 782 | Anticonvulsants (hydantoins) | Alter Na⁺ channels in CNS → ↓seizure potential (ch) | Seizure prevention; status epilepticus, head injury/ICH transports (ch) | Hypotension, dysrhythmias with fast IV phenytoin (standard); protein-binding interaction with valproic acid (p 747) | Per facility/protocol |
| Benzodiazepines (see Section 2) • p 781 | — | — | First-line for persistent seizures; sedation, anxiety (ch) | — | — |
8. GI — Acid Reducers & Antiemetics — pp 782–783
| Drug (generic, brand) • page | Class / type | What it does (plain language) | What it treats (indications) | Key contraindications / cautions | Typical adult teaching dose / route |
|---|---|---|---|---|---|
| Famotidine (Pepcid), Cimetidine (Tagamet) • pp 782–783 | H2 receptor antagonists (-tidine) | Block histamine at stomach parietal cells → ↓acid (ch) | Acid-related GI conditions/ulcers; adjunct in allergic reactions (ch) | Famotidine ↓absorption of some drugs (p 746); cimetidine many interactions (standard) | Famotidine 20 mg IV (standard); per protocol |
| Ondansetron (Zofran); Granisetron (Kytril), Dolasetron (Anzemet) • p 783 | 5-HT3 receptor antagonists (-setron) | Block serotonin receptors in brain/GI that trigger vomiting (ch) | Nausea/vomiting; ODT avoids IV (ch) | QT prolongation (ch); does not work for motion sickness (ch) | Ondansetron 4 mg IV/IM/ODT (standard) |
| Promethazine (Phenergan), Prochlorperazine (Compazine) • p 783 | Phenothiazine antiemetics (-azine); also antipsychotic | Act on dopamine receptors in brain → inhibit vomiting (ch) | Nausea/vomiting (ch); promethazine potentiates antitussives (p 746) | Promethazine: IV tissue injury (ch). Prochlorperazine: hypotension if fast IV (ch). Dystonic reactions → treat with diphenhydramine (ch). Sedation | Per protocol (dilute, slow; deep IM preferred for promethazine — standard) |
| Metoclopramide (Reglan) • p 783 | Prokinetic antiemetic | Enhances ACh in upper GI → ↑motility & gastric emptying (ch) | Nausea/vomiting, gastric emptying (ch) | Dystonic reactions → diphenhydramine (ch) | 10 mg slow IV (standard); per protocol |
| Octreotide (Sandostatin) • p 783 | Somatostatin analog | ↓ hormone secretion; ↓ blood flow in esophageal vessels (ch) | Bleeding esophageal varices (interfacility) (ch) | Bradycardia, chest pain (ch) | Infusion per sending facility |
9. Miscellaneous Prehospital Medications (antidotes, electrolytes, metabolic) — pp 784–786
| Drug (generic, brand) • page | Class / type | What it does (plain language) | What it treats (indications) | Key contraindications / cautions | Typical adult teaching dose / route |
|---|---|---|---|---|---|
| Acetaminophen (Tylenol, APAP) • p 784 | Antipyretic / mild analgesic (non-NSAID) | Lowers fever; mild pain relief (ch) | Fever, adjunct analgesia, prevent febrile seizures in children (ch) | Not for environmental/drug-induced hyperthermia (ch); overdose → delayed liver failure (ch); confirm liquid concentration (ch); no PO if seizure/airway risk (ch) | 650–1,000 mg PO or 1 g IV over 15 min (standard); per protocol |
| Ketorolac (Toradol) • p 785 | NSAID | Inhibits prostaglandins → ↓pain & inflammation (ch) | Pain; opioid alternative/adjunct (ch) | GI bleeding risk (ch), injection-site pain, headache (ch); renal impairment, bleeding, pregnancy, ASA/NSAID allergy (standard) | 15 mg IV or 15–30 mg IM (standard); per protocol |
| Diphenhydramine (Benadryl) • pp 784–785 | Antihistamine — competitive H1 antagonist | Blocks histamine at H1 receptors (ch) | Anaphylaxis adjunct; mild allergic reactions; dystonic/EPS reactions; itching; rhinorrhea; mild sedative/antitussive (ch) | Sedation, palpitations, anxiety; anticholinergic effects; overdose can be fatal (ch) | 25–50 mg IV/IM (standard) |
| Dextrose (D50, D25, D10) • p 784 | Carbohydrate / antihypoglycemic | Directly raises blood glucose | Known or suspected hypoglycemia (ch) | Extravasation → tissue necrosis — confirm patent IV (ch); rebound hypoglycemia — recheck (ch); thiamine first in malnourished/alcoholic (p 786) | D50 25 g (50 mL) IV, or D10 in 100-mL increments (standard) |
| Glucagon (GlucaGen) • p 785 | Pancreatic hormone (hyperglycemic agent) | Converts liver glycogen → glucose; ↑HR & contractility without β1; relaxes GI smooth muscle (ch) | Hypoglycemia without IV access; beta-blocker & CCB overdose; esophageal food bolus (with OLMC) (ch) | Onset 5–20 min IV, ~30 min IM; short-lived — watch for recurrence; IV dextrose still preferred (ch). N/V (standard) | Hypoglycemia: 1 mg IM/IV (standard); OD doses per protocol |
| Thiamine (vitamin B1) • p 786 | Vitamin | Replaces B1; prevents Wernicke encephalopathy (ch) | Malnourished/chronic alcohol use, before dextrose (ch) | Adverse effects unlikely (ch) | 100 mg IV or deep IM (standard) |
| Calcium chloride / Calcium gluconate • p 784 | Electrolyte | Restores calcium; stabilizes cardiac membrane | CCB overdose, Mg toxicity, hyperkalemia, hypocalcemia, hydrofluoric acid exposure, pre-verapamil (ch) | Not routine in arrest (ch). Chloride ≈ 3× elemental Ca of gluconate; vein irritant — slow IV, watch extravasation; no IM/SubQ; precipitates with other drugs (esp. bicarb) (ch); digoxin pts sensitive (p 773) | CaCl 10% 1 g (10 mL) slow IV, or Ca gluconate per protocol (standard) |
| Magnesium sulfate • pp 785–786 | Electrolyte; smooth-muscle relaxant | ↓ membrane excitability, slows AV conduction; bronchodilation & tocolysis (ch) | Torsades de pointes, hypomagnesemia, eclampsia/pre-eclampsia seizures, refractory asthma (ch) | Toxicity: respiratory depression, ↓muscle tone, loss of DTRs → stop infusion, give calcium (ch); hypotension with fast push | Torsades 1–2 g IV; eclampsia 4–6 g IV over 15–20 min; asthma 2 g (standard) |
| Sodium bicarbonate • p 786 | Alkalinizing agent (buffer) | Raises blood pH; shifts K⁺; Na⁺ load stabilizes heart in TCA OD (ch) | Severe metabolic acidosis, hyperkalemia, tricyclic antidepressant OD, salicylate excretion (ch) | Incompatible with calcium & catecholamines in same line (ch); alkalosis, fluid overload, electrolyte problems, cerebral/pulmonary edema (ch) | 1 mEq/kg IV (standard); per protocol |
| Tetracaine • p 786 | Ophthalmic local anesthetic | Numbs the eye surface (ch) | Before Morgan lens/eye irrigation (ch) | Don't give to patient to take home (standard) | 1–2 drops per eye (standard) |
10. Classes to Recognize — Name Stems (p 730) and the Chapter's Drug Tables
Generic names often carry a stem that links drugs in the same class (p 730). Safety (p 730): don't rely on the stem alone — different classes can share a stem (e.g., tricyclics like amitriptyline vs SSRIs like fluoxetine), and some drugs break the pattern.
| Stem | Class | Examples (chapter page) | Field clue |
|---|---|---|---|
| -olol / -alol | Beta blockers | Metoprolol, propranolol, labetalol, sotalol (p 760, 776) | ↓HR/BP; bronchospasm risk; glucagon for OD |
| -pril | ACE inhibitors | Enalapril, lisinopril, captopril, benazepril, ramipril (pp 730, 776) | Cough, angioedema |
| -sartan | Angiotensin II receptor blockers | Losartan, valsartan, irbesartan, candesartan (p 776) | HTN/HF home meds |
| -statin | Cholesterol-lowering (statins) | Atorvastatin, simvastatin, pravastatin, lovastatin (p 776) | Cardiac-risk history clue |
| -am (-azepam / -zolam) | Benzodiazepines | Diazepam, lorazepam, clonazepam, temazepam, midazolam (pp 730, 765) | Seizures, sedation; synergism with opioids |
| -terol | Beta-2 agonist bronchodilators | Albuterol, levalbuterol, salmeterol, formoterol (p 760) | Asthma/COPD |
| -lukast | Leukotriene receptor antagonists | Montelukast, zafirlukast (p 768) | Long-term asthma only |
| -sone / -olone | Corticosteroids | Dexamethasone, prednisone, methylprednisolone (p 767) | Inflammation; ↑glucose |
| -curonium | Nondepolarizing paralytics | Rocuronium, vecuronium (p 767) | No sedation — must sedate |
| -tidine | H2 blockers | Famotidine, cimetidine (p 783) | Acid; allergy adjunct |
| -setron | 5-HT3 antiemetics | Ondansetron, granisetron, dolasetron (p 783) | QT prolongation |
| -azine | Phenothiazines | Promethazine, prochlorperazine (p 783) | Dystonia → diphenhydramine |
| -parin | Heparins | Heparin, enoxaparin (p 779) | Bleeding |
| -xaban / -gatran | Direct oral anticoagulants | Rivaroxaban, apixaban, edoxaban / dabigatran (p 780) | Bleeding in trauma |
| -grel | P2Y12 antiplatelets | Clopidogrel, prasugrel (p 780) | Bleeding |
| -plase | Fibrinolytics | Alteplase (Activase) (p 780) | Time-critical, hemorrhage |
| -afil | PDE-5 inhibitors (erectile dysfunction) | Sildenafil, tadalafil (p 774) | No nitroglycerin |
| -thiazide | Thiazide diuretics | Hydrochlorothiazide, chlorothiazide (p 775) | Low K⁺ |
| -azosin | Alpha-1 blockers | Prazosin (p 776) | Orthostatic hypotension |
11. Rapid-Recall Flashcards
| Question | Answer |
|---|---|
| "One heart, two lungs" — what does that mean? | Beta-1 = heart (↑rate, force, conduction). Beta-2 = lungs (bronchodilation). |
| Order the sympathomimetics from pure alpha to pure beta. | Phenylephrine → norepinephrine → epinephrine → isoproterenol. |
| Competitive vs noncompetitive antagonist — give one example of each. | Competitive (can be out-competed): naloxone, atropine. Noncompetitive (permanent): aspirin on platelet COX (up to 10 days). |
| Why might atropine fail in a bradycardic patient? | Bradycardia from 2nd-degree type II or 3rd-degree AV block isn't vagal — atropine is unlikely to work; pace/pressor per protocol. |
| Atropine dose limit in organophosphate poisoning? | None — give repeatedly until secretions/respiratory and hemodynamic status improve. It won't fix nicotinic weakness/fasciculations. |
| Patient took tadalafil yesterday and now has chest pain — nitro? | No. PDE-5 inhibitor + nitroglycerin → severe, refractory hypotension. Also caution in RV infarct. |
| Which paralytic causes fasciculations and malignant hyperthermia risk? | Succinylcholine (depolarizing; onset <60 s, lasts 4–6 min). |
| Antidote for beta-blocker overdose that bypasses the beta receptor? | Glucagon (↑HR and contractility without activating β1). Also used in CCB OD. |
| Magnesium toxicity signs and antidote? | Respiratory depression, ↓muscle tone, loss of deep tendon reflexes → stop infusion, give IV calcium. |
| Name three indications for sodium bicarbonate. | Severe metabolic acidosis, hyperkalemia, tricyclic antidepressant overdose (also salicylate excretion). |
| Promethazine/metoclopramide caused neck twisting and jaw spasm — treatment? | Dystonic reaction → IV diphenhydramine. |
| Why give an alpha blocker before labetalol in cocaine-induced hypertension? | To avoid unopposed alpha stimulation causing uncontrolled hypertension. |
| ACE inhibitor patient with massive tongue swelling — what's different? | ACE-inhibitor angioedema responds poorly to epi/antihistamines; prepare for a very difficult airway. |
| TXA time window? | Within 3 hours of injury; after 3 hours complications increase. |
| Adenosine pearls? | Half-life <10 s; rapid push + flush; 5–15 s pause is expected; run a continuous ECG strip. |