I rank Atropine 12 out of the 33 drugs we carry.

Aside from routine use in cardiac arrest, I use Atropine two or three times a year for patients with symptomatic bradycardia. I have no reason to believe it does any good at all in cardiac arrest, but as far as symptomatic bradycardia, as long as the patient is not in a third-degree block, I have had good success with Atropine.

Earlier in my career, I used Atropine a bit more, but that was before I knew that many people thanks to beta blockers had every day pulses in the high 40’s, low 50’s. I also used to more readily give it to a patient having an MI (heart attack), which can increase their oxygen demand and cause more damage. Now I only give it to patients having an MI if they are hypoperfusing. Ah, the learning curve.

The best bradycardia calls are for the patient passed out in the bathroom. You find them on the floor, cold and clammy, no pressure, pulse in the 20’s. Straining to go to the bathroom, their vagus nerve overpowered them, knocking their heart rate down and they lacked the ability to rebound on their own. We used to give a full amp of Atropine, now we give 0.5, and if that doesn’t work another 0.5 mg, etc. A couple times I have given the full 1 mg by mistake. Old dogs. Still the drug works well, the pulse picks up, the patient wakes up, the skin colors up and drys out and all is well in paramedic land. “You fixed them,” the doctor says to me in the ED. Music to my ears.

If I don’t have atropine in my kit, I can always pace the patient. Other options are Dopamine and an epi drip.

***

We can also give Atropine to organophosphate poisionings, but I have never had one.

***

Atropine (Atropine Sulfate)

Class: Antimuscarinic
Parasympathetic blocker
Anticholinergic

Action: Blocks acetylcholine (ACh) at muscarinic sites

Indication: Symptomatic bradyarrhythmias
Cholinergic poisonings
Asystole
Refractory bronchospasm

Contraindication: Relative contraindication wide complex bradycardia in the setting of acute ischemic chest pain

Side effects: Tachyarrhythmias
Exacerbation of Glaucoma
Precipitation of myocardial ischemia

Dose: Bradyarrhythmias – 0.5mg , may repeat every 3-5 minutes

Asystole – 1mg MR q 3-5 minutes (total max. dose 3mg)

Organophosphate poisonings – 1mg – 2mg; may repeat as needed

Route: IV push

Pedi dose: 0.02mg/kg IV

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I rank Dopamine 13 out of the 33 drugs I carry.

We use Dopamine for cardiogenic shock or septic shock refractory to fluids.

I have never used a lot of Dopamine over the years. When I started we carried Dopamine in vials and had to mix up our own drips. Working as a single medic, if I had a patient who needed Dopamine, they usually needed too much attention from me for me to break away and mix up a drip (and we had fairly short transports to the hospital). Over the years I have grown more comfortable with mixing drips, while at the same time we now carry a premixed Dopamine. Lately I have started to use Dopamine more with return of spontaneous circulation (ROSC) from cardiac arrest. I have had success to the extent that where before I often lost pulses after regaining them as the epinephrine wore off, I have had many more patients gain and hold a decent pressure once I have the Dopamine hung. Still, most of these patients end up dying in the ICU.

If I am giving someone Dopamine, as I said before, they are pretty bad off. I have only ever given it twice for septic shock after having dumped a liter of fluid into a patient with no change in hypotension, but I don’t know the patients’ final outcomes.

I rate Dopamine where I do because it at least has the potential to be a lifesaver.

We don’t carry med pumps so the drip is pretty much of an eyeball, and then titrate to blood pressure. When you have no pressure, you bump it up. You get a pressure above 90, you ease it down.

Several times at the hospital I have had to warn nurses about shutting the Dopamine off completely. Recently I brought in a cardiac arrest ROSC with a BP of 120-something systolic, the nurse shut off (unhooked) the Dopamine because the pressure was good. I said, you might not want to do that, but she never hooked it back up, and when I came back from writing my run form,they were doing CPR. They eventually got pulses back and ended up putting the patient back on Dopamine. Like so many others, she made it to the ICU only to die within a few days.

I only used Dopamine once last year, but have used it twice so far this year. All three cases were post-rescucitation care.

***

Dopamine (Intropin)

Class: Naturally occurring catecholamine, adrenergic agents

Action: Stimulates α, β1 and dopaminergic receptors

Effects: 0.5 to 2 μg/kg/min – Renal and mesenteric vasodilation.
2 to 10 μg/kg/min – Renal and mesenteric vasodilation persists and
increased force of contraction (FOC).
10 to 20 μg/kg/min – Peripheral vasoconstriction and increased FOC (HR may
increase).
20 μg/kg/min or greater – marked peripheral vasoconstriction (HR may
increase).

Indication: Shock – Cardiogenic
- Septic
- Anaphylactic

Contraindication: Pre-existing tachydysrhythmias or ventricular dysrhythmias.

Precaution: Infuse in large vein only
Use lowest possible dose to achieve desired hemodynamic effects,
because of potential for side effects.
Do not D/C abruptly; effects of dopamine may last up to 10 minutes after drip
is stopped.
Do not mix with NaHCO3 as alkaline solutions will inactivate dopamine.

Side effect: Tachydysrhythmias
Ventricular ectopic complexes
Undesirable degree of vasoconstriction
Hypertension relate to high doses
Nausea and vomiting
Anginal pain

Dose: 2.0 – 20. μg/kg/min titrated to desired effect

Route: IV drip

Pedi dose: same as adult dose – titrate to effect

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I rank Zofran 14 out of the 33 drugs I carry.

Zofran is an anti-emetic. When I started as a medic, we had Dramaine for motion-sickness, nausea. Then we got Reglan, then we got Phenergan, and now (once it went generic) finally we have Zofran. All I can say is Horray for Zofran!

I gave Zofran to more patients (41) last year than any other drug, more than aspirin, more than nitro, more than breathing treatments. It is a excellent drug. I give it to anyone who is vomiting or nauseaous. While it hasn’t worked on every patient, since we got Zofran, it is an extremely rare event that I got vomitted on. And while a few patients may continue to feel nauseous, most say they feel better.

In putting together this list, it is hard to weigh all the variables: does the drug safe lives? does it do something that needs to be done right away? does it make the patient feel better? does it truly work? and often do I use it?

I can’t say that Zofran is a life-saving drug, but it is an excellent comfort drug. It is rare that I am ever nauseous, but the few times I have been, it is a truly awful experience. It makes you feel subhuman, pathetic, and puny. Zofran gives patients their dignity back, in addition to keeping the floor of my ambulance clean.

I keep a stash of Zofran in my bench seat IV tray, next to the Aspirin and Nitro, so it is right there at the handy.

“This should help with your nausea,” I say.

Horray for Zofran!

***

Ondansetron (Zofran)

Class: Antiemetic; Serotonin Receptor Antagonist, 5-HT3

Action: Selectively antagonizes serotonin 5-HT3 receptors

Indication: Nausea; Vomiting

Contraindication: Hypersensitivity to Ondansetron

Precautions: Hypersensitivity to other selective 5-HT3 antagonists
Adverse effects: Headache (40% incidence)
QTc Prolongation
Tachycardia; Anginal chest pain (rare)
Constipation; diarrhea; dry mouth
Dizziness (5% incidence)
Transient Blindness (rare)
Pregnancy Class: B

Adult Dose: 4 mg or Slow IV over 2 – 5 minutes

Pediatric Dose: 0.1 mg/kg (max. single dose of 4 mg) IM or slow IV over 2 –
5 minutes

Routes: Slow IV over 2 – 5 minutes

Notes: Ondansetron causes less sedation and incurs minimal risk of
dystonia as compared to other antiemetics such as
Promethazine (Phenergan ®), prochlorperazine
(Compazine®), or Metoclopramide (Reglan®).

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I rank Cardizem 15 out of the 33 drugs I carry.

We didn’t have Cardizem when I started as a medic. If we had someone in rapid afib and they were unstable enough we could shock them. I never had such a patient, and a good thing. As I have said before, I am not a fan of electricity unless my patient is in vfib or VT without a pulse. Shocking talking people — not for me. I remember many years ago when I was a brand new EMT in Massachusetts, we had taken a patient into a small hospital and there in the ED they had a young man in a rapid tachycardia that they hadn’t been able to break with medicine. They had given him a sedative, and after waiting for it to take hold, applied the shock. The kid, who was probably fifteen or so, but with the build of a football player, came off the table in pain, and then he lay there on his side whimpering. They still hadn’t broken the rhythm. They gave him some more sedative, and waited. I couldn’t stand to watch it. I heard his scream from the entryway.

Once we got Cardizem, it took me a little while to get the hang of it. You have to push it slowly, and you need to be patient. It is not the sudden fix that Adenosine is. Initially I was frustrated because while I would get a response (the rapid afib might decline from the 160-170’s to the 110-120’s, by the time I was in triage it would be back up in the 150-160 range). I started giving a small rebolus that seemed to help. Eventually, we had drips added to our guidelines and now I always hang a drip. I put 25 mg in a 250 ml bag. I set it at 5mg/hr and if I notice the rate inching up, I up the drip. It works great. I usually always do two lines, one to give the Cardizem through and one in case their pressure drops and I need to give them a bolus.

I do rapid afibs fairly often in the town I work in because of the large elderly population. The call usually comes in as an elderly person feeling weak and dizzy. I may find them sitting in a recliner, pale, and just looking sick. I did one just last week. I remember saying to my partner it sounded like the prototypical call in our town, old sick person wants to go the hospital, likely they have the flu. In the house, I introduce myself and my partner, ask a few quick questions (how to you feel? any trouble breathing? any pain?) and inquire what hospital they want to go to. I help them to the stretcher and then we take them out to the ambulance. Unless someone is really sick or having chest pain, I rarely do much in the house. Out in the ambulance, if I haven’t already done so, I get them in a Johnny, listen to their lungs, and while my partner gets a blood pressure, I put them on the heart monitor. Sometimes, I just tell my partner to head to the hospital nonpriority while I do the BP.

So I put the guy on the monitor, and son of a gun… “Well, there’s your problem,” I say.

Our Cardizem used to come in a syringe with powder in one chamber and a dilutant in the other that we would mix together, now it comes in a vial that we have to keep chilled or else we have to change it out every month. Since we got the cooler for the hypothermia protocol, we keep our Cardizem in there. Well, I put in a line and then draw up the Cardizem; I go into my rapid afib talk. “It’s pretty common in people as they age — it is not a heart attack. Remember when the elder George Bush passed out and threw up on the Japanese ambassador (they all remember) — his problem was he was in rapid afib. It can be controlled with medicine.” I explain the anatomy of the heart, the atria and the ventricles, and how his atria are not pumping properly, not flushing all the blood out and how longterm if not corrected this can lead to a stroke. I tell them the medicine I am about to give them should slow their heart down to a more normal rate and they should start feeling better. And they usually do.

The American Heart Association 2005 Guidelines include a line in their rapid afib algorithm that we do not include in ours. That line is “expert consultation.” It comes before cardizem. More specifically, they write “We recommend a 12-lead ECG and expert consultation if the patient is stable.” I was at an EMS conference shortly after the guidelines came out and was able to ask a doctor who had participated in writing this section of the guidelines what the AHA meant by the “expert consultation” line, and he basically said, it meant if the patient was stable, medics should leave them alone until a doctor can examine the patient.

It is hard to disagree with that, but at the same time, while the patient is stable, they are feeling pretty miserable and at least in our area, if we don’t give them Cardizem, the ED will, so the doctors at our medical advisory committee felt the paramedics could be trusted to go ahead and make the patient more comfortable and take care of the problem. They basically left the choice up to us. If the patient is feeling crappy, and there are no contraindications, I usually give them the Cardizem. If they say they feel great and are only going to the hospital because they were at the doctors for a routine physical and the doctor while doing a routine ECG, discovered they were in a rapid afib in the 160s, then I leave it alone.

***

Diltiazem (Cardizem)

Class: Calcium channel blocker

Action: Partial blockade of AV node conduction

Indication: Atrial fibrillation, Atrial flutter, narrow complex tachycardia

Contraindication: Hypotension
Hypersensivity to drug
Wide complex tachycardia
Known history of Wolf Parkinson White (WPW)
2° or 3° AV block

Relative contraindication: Already on Digoxin and Beta Blocker

Side effect: May induce VF if given to patient with wide complex tachycardia that is due to WPW.
May cause hypotension

Dose: Initial dose: 0.25mg/kg slow IV (average dose 20mg in adult male)
May repeat with 0.35 mg/kg (25 mg average) in 10-15 minutes if no or
diminishing effect. Decrease by 5 mg per bolus for elderly (>70 yr/old).

Route: IV push (bolus) given over 2 minutes; reconstitute according to
manufacturer’s recommendation.

Pedi dose: 0.25mg/kg

Important points: If patient is hypotensive secondary to drug administration:
- If not in failure give IV fluids
- If bradycardic administer CaCl2
- If still bradycardia give Atropine
- Transcutaneous pacing may be necessary for markedly symptomatic
bradycardia.
- If CHF is present or worsens administer Dopamine infusion
- If all of above fail (persistent hypotension >2-5 minutes) administer glucagon
1 mg IV

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My choices are getting harder and harder as my drug box shrinks.

Alas, today I rank Adenosine 16 out of the 33 drugs I carry.

I wrote quite a bit about Adenosine a few months ago in a post Adenosine/PSVT that first got me thinking about doing a series on the drugs I carry in my med bag.

While I only give Adenosine a few times a year, it has always been one of my favorite drugs. It is a great paramedic drug because you can fix the problem on the spot and the results are dramatic. Someone calls 911 because they are weak and clammy and they feel this rapid palpitating in their heart. You try to feel a pulse and you can’t. You put them on the monitor and behold they are cranking away at 220. You turn the monitor toward your partner and away from the patient’s view. My hands always used to shake when I’d do the IV for this type of patient (prestage performance anxiety). Fortunately this patient has a nice big fat AC and the catheter easily sinks in.

You carefully explain what you are about to do, how you will inject some medicine in the IV line that will soon fix their problem, while it may make them feel a little strange, but that strange feeling will pass quickly, you add. You slam the drug in, followed by a flush. The person gets a weird expression on their face, while your audience – partner, bystanders gasp as the monitor goes asystole, and then weird funky beat, weird funky beat and then a few more weird beats and the person is back in a regular rhythm at 80, and they feel so much better and you feel so much better and you print out the strips and show the printout to the patient and say this was your heart going 220 and then here’s what happened when I gave you the medicine and you felt all weird, see that flat line — that was you — and then here’s you now, good as new, and you — the paramedic — are everybody’s hero.

So why only 16 out of 32? Well, there are many great drugs still to come, and while great, if I didn’t have Adenosine, I could try Cardizem or Amiodarone, or if I have to, I could shock the person back to a regular rhythm (I’m not a big fan of this).

I have had a few patients who found Adenosine so uncomfortable, that they have asked to be cardioverted (shocked) instead. Once I offered a trial of Cardizem and it worked great. There was no dramatic asystole, just an easy slowing. The other patient I convinced to let me give them Adenosine with success.

Farewell, Adenosine, old friend. (I am glad it is only a mock farewell.)

***

Adenosine (Adenocard)

Class: Endogenous nucleoside

Action: Stimulates adenosine receptors; decreases conduction through the AV node

Indication: PSVT

Contraindication: Patients taking Persantine or Tegretol.

Precaution: Short half-life must administer rapid normal saline bolus immediately after
administration of drug. Use IV port closest to IV site.

Side effect: Arrhythmias, chest pain, dyspnea, bronchospasm (rare)

Dose: Adult – 6mg IV over 1-2 seconds; may repeat 12mg twice at 2 minute
intervals. Pedi – 0.1mg/kg, may repeat twice at 0.2mg/kg

Route: Rapid IV push, followed by a flush

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