H-1 Benzodiazepines V4

Home , Ketazolam

Wilson County Emergency Management Agency Protocol Manual Drug Reference

Benzodiazepines

• generic Brand equivalent

• alprazolam: Xanax; Kalma; Apo-Alpraz; Novo-Aloprazol; Nu-Alprax; Tafil

• bromazepam: Lexotan; Lexomil

• chloridazepoxide: Librium; Nova-Pam; Apo-chlordiazepoxide; Corax; Medilium; Novo-Poxide; Solium

• clobazam: Frisium

• clonazepam: Klonopin; Rivotril

• clorazepate: Gen-Xene; Tranxene; Apo-Clorazepate; Novo-Clopate

• diazepam: Valium; Ducene; Antenex; D-Pam; Pro-Pam; Apo-Diazepam; Diazemuls; E Pam; Meval; Novo-Dipam; PMS-Diazepam; Vivol

• estazolam: ProSom; Tasedan

• flunitrazepam: Rohypnol; Hypnodorm

• flurazepam: Dalmane; Apo-Flurazepam; Novo-Flupam; PMS-Flupam; Somnol; Som Pam

• halazepam: Paxipam

Drug Reference – Benzodiazepines Page 1 of 2 H - 1 Wilson County Emergency Management Agency Protocol Manual Drug Reference

• ketazolam: Anxon

• loprazolam: Dormonoct

• lorazepam: Ativan; Apo-Lorazepam; Novo-Lorazepam; Nu-Loraz; PMS-Lorazepam; Pro-Lorazepam

• lormetazepam: Noctamid

• medazepam: Nobrium

• midazolam: Versed; Hypnovel; Dormicum

• nitrazepam: Mogadon; Alodorm; Insoma; Nitrados

• oxazepam: Serax; Serepax; Murelax; Alepam; Serenid; Benzotran; Apo-Oxazepam; Novo-Oxazepam; Oxpam; PMS- Oxazepam; Zapex

• prazepam: Centrax

• quazepam: Doral

• temazepam: Restoril; Euhypnos; Normison; Temaze; Euhypnos; Nocturne; Normison; Temaze; Temtabs; Sompam

• triazolam: Halcion; Apo-Triazo; Gen-Triazolam; Novo-Triolam; Nu-Triazo; Hypam; Tricam

Drug Reference – Benzodiazepines Page 2 of 2 H - 1 Wilson County Emergency Management Agency Protocol Manual Protocols

Amiodarone Infusion

Stable Rhythm

Bolus Mix 150 mg in 100 ml. Refer to the Amiodarone Mixture Procedure I – 1.

Maintenance Drip Due to the extended half-life of this medication, a Maintenance drip can be post postponed until arrival at the ER.

Special Notes Utilize a gravity control device (IV Stat2) to administer this medication.

VF/Pulseless VT Initial dose - 300 mg in 20 ml given over 2 minutes Secondary dose 150 mg in 20 ml given over 2 minutes

Drug Reference - Amiodarone Page 1 of 1 H - 2

Drug Reference - Calculations H - 4 Drug Reference - Calculations Drug Reference - Calculations H - 4 Drug Reference - Calculations H - 4 Drug Reference - Calculations H - 4 Drug Reference - Calculations H - 4 H - 4 Drug Reference - Calculations Drug Reference - Calculations H - 4 Drug Reference - Calculations H - 4 Wilson County Emergency Management Agency Protocol Manual Protocols

Adult Epinephrine Drip (Hypotension/Bradycardia)

2mg/500ml (4mcg/ml)

Dose (mcg/minute) Infusion Rate (ml/hour)

1 15 1.5 22 2 30 2.5 37 3 45 3.5 52 4 60 5 75 6 90 7 105 8 120 9 135 10 150

Special Notes • This medication should be administered through a gravity control device • Epinephrine should be 1:1,000 concentration

Drug Reference – Epi Chart (Hypotension/Brady) Page 1 of 1 H - 5 Wilson County Emergency Management Agency Protocol Manual Protocols

Epinephrine Drip Chart (Mast Cell Activation)

2mg/500ml (4mcg/ml)

Dose (mcg/minute) Infusion Rate (ml/hour)

4 60 5 75 6 90 7 105 8 120 9 135 10 150

Special Notes • This medication should be administered through a gravity control device • Epinephrine should be 1:1,000 concentration

Drug Reference – Epi Chart (Mast Cell) Page 1 of 1 H - 6 Wilson County Emergency Management Agency Protocol Manual Protocols

Lidocaine Drip Chart - Adult

1000mg/250ml (4mg/ml)

Dose (mg/minute) Infusion Rate (ml/hour)

1 15 2 30 3 45 4 60

Special Notes This medication should be administered through a gravity control device (IV stat 2)

Drug Reference – Lidocaine Drip Page 1 of 1 H - 7 Acetaminophen (Tylenol®) Class: Analgesic and antipyretic agent Packaging: 160 mg / 5 ml in oral solution Dose: 15 mg / kg, MAX DOSE – 500 mg Action: has been shown to inhibit the action of endogenous pyrogens on the heat- regulating centers in the brain by blocking the formation and release of prostaglandins in the central nervous system Onset: 0.5 – 1 hour Duration: 3 – 8 hours Indications: A fever of 100.4 or greater, post febrile seizure Contraindications: Inability to swallow. Unconsciousness. Hepatic disease Precautions: Use with caution by mouth if note AMS or lethargy

Adenosine (Adenocard®) Class: Antiarrhythmic Packaging: 12 mg / 4 ml (Vial) Dose: 12 mg IV / IO Max Dose: 36 mg Action: It slows the conduction through the atrioventricular (AV) node and interrupts the reentry pathway. Onset: Immediate Duration: 20 – 30 seconds (Peak @ 10 seconds) Indications: Supraventricular Tachycardia / paroxysmal supraventricular tachycardia Contraindications: AV blockages, Sinus node disease, WPW Syndrome Precautions: Will not convert Atrial or Ventricular dysrhythmias

Medication References H - 8

Albuterol Class: A beta-2 adrenergic stimulant Packaging: 2.5 mg / 3 ml solution (premixed) Dose: 2.5 mg (Nebulized) Action: Causes bronchodilation by stimulating the beta-2 receptor Onset: 5 – 15 minutes Duration: 3 – 4 hours Indications: Bronchospasms: (Asthma / COPD) Contraindications: Tachy-dysrhythmias Precautions: It will cause an increase in heart rate; multiple doses in patients with a history of cardiovascular disease

Amiodarone Class: Antidysrhythmic Packaging: 150 mg / 3 ml in vial Dose: Varies upon protocol Action: Suppresses ventricular ectopy by prolonging the action potential and refractory periods. Slows the sinus rate and increases the PR and QT intervals Onset: 2 – 5 minutes Duration: Variable Indications: Life-threatening dysrhythmias Contraindications: Patients with a known hypersensitivity to the drug. Because it may decrease automaticity, conductivity, and contractility, do not use in the presence of cardiogenic shock, severe sinus bradycardia, or advanced AV block unless a pacemaker is available Precautions: Pregnancy. Nursing women. Use in pediatrics.

Medication References H - 8

Amiodarone Drip Class: Antidysrhythmic Packaging: Adult: Mix 150 mg in 50 ml D5 bag, Ped: Mix 150mg in 100 ml D5 bag Dose: Varies upon protocol Action: Suppresses ventricular ectopy by prolonging the action potential and refractory periods. Slows the sinus rate and increases the PR and QT intervals Onset: 2 – 5 minutes Duration: Variable Indications: Life-threatening dysrhythmias Contraindications: Patients with a known hypersensitivity to the drug. Because it may decrease automaticity, conductivity, and contractility, do not use in the presence of cardiogenic shock, severe sinus bradycardia, or advanced AV block unless a pacemaker is available Precautions: Pregnancy. Nursing women. Use in children.

Aspirin (Acetylsalicylic Acid) Class: NSAID / Antiplatelet Packaging: 81 mg tablets Dose: 324 mg (PO) Action: Impedes clotting by blocking prostaglandin synthetase action, which prevents the formation of the platelet aggregating substance thromboxane A2. Onset: 5 – 30 minutes Duration: 1 – 4 hours Indications: Cardiac Chest Pain Contraindications: Known Active GI Bleeding, Hypersensitivity, Known history of bleeding disorders, Hepatic impairment, Patient’s < 18 years of age Precautions: History of GERD, GI Bleeding, Currently taking anticoagulation medications, (Contact medical control for further advice if needed)

Medication References H - 8

Atropine: Class: Anticholinergic / Antiarrhythmic / Antimuscarinics Packaging: 0.1 mg / ml (Prefilled Syringe) Dose: Bradycardia: 0 .5 mg IV / See protocol for other Action: Inhibits muscarinic actions of acetylcholine at postganglionic parasympathetic neuroeffector sites. Onset: Immediate Duration: 4 – 6 hours Indications: Bradycardia Contraindications: None in emergency setting Precautions: Patients with s/s of myocardial ischemia or infarction, Glaucoma Special Notes: May not be effective in wide complex bradycardia or high degree AV blocks.

Calcium Chloride 10% Class: Electrolyte Packaging: 1 g / 10 ml (prefilled syringe) Dose: 500 mg to 1000 mg IV (peds 20mg/kg) Action: Acts as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal, and smooth muscles. Maintains cell membrane and capillary permeability Onset: Immediate Duration: Depending on dose, may be up to 4 hours Indications: KNOWN calcium channel blocker overdose / post hemodialysis arrest Contraindications: Cardiopulmonary arrest not associated with calcium channel blocker toxicity, hypocalcemia, or hyperkalemia. Precautions : Calcium chloride should not be administered in the same infusion with sodium bicarbonate since calcium will combine with sodium bicarbonate to form an insoluble precipitate (calcium carbonate). Calcium chloride should be given with extreme caution, and in reduced dosage, to persons taking digitalis because it increases ventricular irritability and may precipitate digitalis toxicity. Medication References H - 8

Dextrose (5%) Class: Hypotonic solution once in the body Packaging: 5% in 50, 100, 500 ml for drug mixtures Dose: Varies by use/protocol Action: Provides a medium for IV medications, provides a small amount of dextrose for cellular metabolism while leaving behind water Onset: Immediate Duration: Remains in intravascular space for 20-40 minutes Indications: Dilution solution for IV medications Contraindications: None Precautions: Diluting to the desired mixture is required.

Dextrose 50% (D50W) Class: Carbohydrate Packaging: 25g in 50 ml (Prefilled Syringe) Dose: Varies by protocol, can be reduced for D25 and D10. Action: Increases blood sugar Onset: Immediate Duration: Dependent upon patient metabolism and degree of hypoglycemia Indications: Hypoglycemia Contraindications: Dextrose is contraindicated in intracranial hemorrhage, increased ICP, and known or suspected CVA in the absence of hypoglycemia. Precautions: Diluting to the desired mixture may be required. Ensure IV patency as infiltration will cause local necrosis.

Medication References H - 8

Diazepam (VALIUM) Class: Anticonvulsant / Sedative Packaging: 10 mg / 2 ml (Carpuject Vial) Dose: Varies by protocol Action: Depresses the CNS by potentiating GABA; Produces skeletal muscle relaxation by inhibiting spinal polysynaptic afferent pathways; has anticonvulsant properties due to enhanced presynaptic inhibition. Onset: IV: 1 – 5 mins // IM: Unknown (Erratic absorption rates) Duration: IV/IM: 15 – 60 mins Indications: Seizure Contraindications: Known hypersensitivity, drug abuse, coma, shock, or head injury Precautions: Use caution if the patient has ingested CNS depressants, May cause a decrease in respiratory drive and apnea.

Diltiazem (CARDIZEM) Class: Calcium Channel Blocker // Antiarrhythmic Packaging: 100 mg (ADD-Vantage® vial) Dose: 0.25 mg/kg (max of 25mg), mixed in 100ml ADD-Vantage® soft saline bag Action: Produces relaxation of coronary vascular smooth muscle and dilation of both large and small coronary arteries at drug levels which cause little or no negative inotropic effect Onset: 2 – 5 minutes Duration: Unknown Indications: Supra Ventricular Tachydysrrythmias: Atrial fibrillation / flutter with RVR Contraindications: Sick sinus syndrome, high degree AV blocks, Recent MI, pulmonary congestion, hypersensitivity, or hypotension Precautions: Hepatic or renal impairment, decreased cardiac function, geriatrics should receive a lower dose and a slower infusion, hepatic or renal failure.

Medication References H - 8

Diphenhydramine (Benadryl) Class: Antihistamine Packaging: 50 mg / 1 ml (Vial) Dose: Adult: IV/IO: 25 mg, IM: 50 mg . Peds: IV/IM: 1 mg / kg Action: Reverses histamine-induced bronchospasm, vasodilation, and increased capillary membrane permeability. Onset : Immediate IV/IO, 20 – 30 minutes IM Duration: 4 – 8 hours Indications: Anaphylaxis. Acute allergic reaction. Extrapyramidal/dystonic reactions Contraindications: Narrow-angle glaucoma. Asthma. Pregnancy Precautions: May cause significant sedation or paradoxical excitation/akethesia. Patients with a history of bronchial asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease or hypertension.

Dopamine Class: Sympathomimetic Packaging: 200 mg / 5 ml (Vial) Dose: 2 – 20 mcg/kg/min (refer to right dose manual) IV, mixed in 250 ml D5% soft bag. Action: Chemical precursor of norepinephrine that stimulates dopaminergic, beta-2- adrenergic, and alpha-adrenergic receptors Onset: 1 – 2 minutes Duration: <10 minutes Indications: Cardiogenic, neurogenic, septic, or anaphylactic shock. Bradycardia with hypotension refractory to Atropine. Hypotension (SBP < 90 mmHg) not secondary to hypovolemia Contraindications: Hypovolemia, Tachydysrhythmias Precautions: Local tissue necrosis can occur with extravasation from peripheral IV

Medication References H - 8

Epinephrine 1:1000 Class: Sympathomimetic Packaging: 1 mg / 1 ml (Ampule) , 30 mg / 30 ml (Multi-dose Vial) Dose: Varies on protocol Action: Sympathomimetic, which stimulates both alpha and beta-adrenergic receptors causing immediate bronchodilation, an increase in heart rate and an increase in the force of cardiac contraction. Onset: IM/SC: 3 – 10 minutes Duration: IM/SC: 5 – 10 minutes Indications: Allergic reaction, MAST cell activation, Croup Contraindications: Known hypersensitivity Precautions: Patients with a history of cardiovascular disease

Epinephrine 1:10,000 Class: Sympathomimetic Packaging: 1 mg / 10 ml (Prefilled Syringe) Dose: Varies upon protocol (Cardiac arrest & Anaphylaxis) Action: Sympathomimetic, which stimulates both alpha and beta-adrenergic receptors causing immediate bronchodilation, increase in heart rate and an increase in the force of cardiac contraction Onset: Less than 2 min IV/IO. Less than 1 min ETT. Duration: 5 – 10 minutes IV/IO/ETT Indications: To restore cardiac rhythm in cardiac arrest. Contraindications: None in cardiac arrest and anaphylaxis Precautions: None in cardiac arrest and anaphylaxis

Medication References H - 8

Epinephrine Drip Class: Sympathomimetic Packaging: 2 mg Epinephrine 1:1000 added to 500 ml 5% Dextrose soft bag Dose: Varies upon protocol Action: Sympathomimetic, which stimulates both alpha and beta-adrenergic receptors causing immediate bronchodilation, increase in heart rate and an increase in the force of cardiac contraction Onset: Immediate Duration: Varies upon infusion Indications: Post-arrest hypotension, bradycardia, MAST Cell activation Contraindications: None in life-threatening events Precautions: None in life-threatening events

Fentanyl Class: Opioid analgesic Packaging: 100 mcg / 2 ml (Carpujet Vial) Dose: Varies by protocol Action: Narcotic agonist-analgesic of opiate receptors: Inhibits ascending pain pathways thus altering the response to pain; increases pain threshold; produces analgesia, respiratory depression, and sedation Onset: IV : Immediate // IM : 7-15 min // IN: Unknown Duration: IV : 30-60 mins // IM : 1-2 hr // IN: Unknown Indications: Pain from an acute traumatic injury / Cardiac Chest Pain Contraindications: Hypersensitivity to drug, Within two weeks of MAOI use Precautions: Patients currently taking or recent use of CNS depressant, use caution when administering in conjunction with benzodiazepines, elderly patients, patients with hepatic or renal impairment

Medication References H - 8

Ipratropium Bromide (Atrovent) Class: Parasympatholytic bronchodilator Packaging: 0.5 mg / 2.5 ml solution (premixed) Dose: 0.5 mg / 2.5 ml solution via nebulizer (Adult and peds the same) Action: Causes bronchodilation, dries respiratory tract secretions Onset: 15 – 30 minutes Duration: 4 – 6 hours Indications: Bronchospasm in patients with reversible obstructive airway disease (asthma, chronic bronchitis, emphysema) and acute attacks of bronchospasm Contraindications: Hypersensitivity to atropine or its derivatives or to soy lecithin or related food products (peanuts) Precautions: Pregnant and nursing mothers

Ketamine Class: Analgesic, Dissociative Analgesic, Anesthetic Dose: Varies on protocol Packaging: 500 mg / 10 ml (Vial) Action: Ketamine is a rapid-acting general anesthetic producing an anesthetic state characterized by profound analgesia, disassociation, normal pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression Onset: IV/IO: 30 seconds // IM: 3 – 4 minutes // IN: 5 – 15 minutes Duration: Varies upon dose and protocol used Indications: Severe pain / Injury / Burns & Extremity extrication Contraindications: Any possibility of an acute MI, CVA, TIA, or any other ischemia. Hypertensive crisis, signs of herniation, Cushing’s Syndrome. Relative Hypertension: Systolic of 180 or Diastolic of 130 Precautions: Patients with a history of coronary artery disease, CHF, and possible increased ICP. Emergence reactions have been shown to occur in approximately 12% of patients.

Medication References H - 8

This medication SHALL not be used to assist and / or facilitate intubation outside the RSI protocol!!!

Medication References H - 8

Ketorolac (TORADOL) Class: Nonsteroidal anti-inflammatory drug (NSAID) Packaging: 30 mg / 1 ml (Carpujet Vial) Dose: Adult 30 mg IV (15 mg if patient is older than 65 yr, or weighs less than 50 kg), 30−60 mg IM Action: Exhibits analgesic, anti-inflammatory, and antipyretic activity Onset: 30 minutes Duration: 45 – 60 minutes Indications: Mild or moderate pain Contraindications: Patients with asthma. Hypersensitivity to Ketorolac, aspirin, or other NSAIDs Precautions: Patients with a history of peptic ulcers; impaired renal or hepatic function; elderly

Lactated Ringers Class: Electrolyte Packaging: 1000 ml in soft bag Dose: Adult 20 ml / kg bolus, Ped 20 ml / kg bolus – IV/IO Action: Assist in fluid replacement due to blood loss or dehydration Onset: Immediate Duration: Individualized Indications: Hypovolemia due to blood loss, burns, dehydration Contraindications: Can’t be used with blood tubing Precautions: CVA, Diabetics, Mixing with blood sets

Medication References H - 8

Lidocaine 2% Class: Antiarrhythmic, anesthetic Packaging: 100 mg / 5 ml (Prefilled Syringe) Dose: Varies by protocol Action: Local anesthetic. Exerts antidysrhythmic action (class Ib) by suppressing automaticity in the His-Purkinje system and by elevating electrical stimulation threshold of the ventricle during diastole. Onset: IV: Immediate // IO: Duration: 10 – 20 minutes Indications: For responsive patients, slow infusion over 60 seconds prior to intraosseous fluid/medication administration. To convert ventricular dysrhythmias (ventricular fibrillation, ventricular tachycardia) in cardiac arrest to sinus rhythm Contraindications: Known hypersensitivity, Stokes-Adams syndrome, and in second- or third-degree heart block in the absence of a pacemaker, WPW (Wolff-Parkinson- White syndrome). Allergy to -caine related anesthetics Precautions: Patients with liver or renal disease, CHF, marked hypoxia, respiratory depression, hypovolemia, shock; myasthenia gravis; debilitated patients, the elderly; family history of malignant hyperthermia (fulminant hypermetabolism). Pregnancy

Medication References H - 8

Lidocaine Drip Class: Antiarrhythmic Packaging: 2 g per 500 ml soft bag Dose: Adult: 1 – 4 mg / min // Ped: 20 – 50 mcg / kg / min, IV/IO Action: Exerts antidysrhythmic action (class Ib) by suppressing automaticity in the His- Purkinje system and by elevating electrical stimulation threshold of the ventricle during diastole. Onset: Immediate Duration: 10 – 20 minutes Indications: If maintenance infusion is needed following VT/VF conversion Contraindication: Known hypersensitivity, Stokes-Adams syndrome, and in second- or third-degree heart block in the absence of a pacemaker, WPW (Wolff-Parkinson- White syndrome). Allergy to -caine related anesthetics Precautions: Patients with liver or renal disease, CHF, marked hypoxia, respiratory depression, hypovolemia, shock; myasthenia gravis; debilitated patients, the elderly; family history of malignant hyperthermia (fulminant hypermetabolism)

Magnesium Sulfate 10% Class: Electrolyte Packaging: 1 g / 2 ml in vial Dose: Varies on protocol Action: Essential for the activity of many enzymes. Plays an important role in neurotransmission and muscular excitability. Acts as a physiological calcium channel blocker and blocks neuromuscular transmission of calcium. Smooth muscle relaxant. Onset: IV: 3 – 5 minutes Duration: 30 minutes Indications: Severe asthma attack / Eclampsia Contraindications: Patients with myocardial damage, heart block, shock, persistent hypertension, hypocalcemia Precautions: Impaired renal function, digitalized patients, concomitant use of other CNS depressants or neuromuscular blocking agents

Medication References H - 8

Methylprednisolone Class: Steroid Packaging: 125 mg / 2 ml (Act-O-Vial®) Dose: Varies on protocol Action: Reduces inflammation by multiple mechanisms. As a steroid, it replaces the steroids that are lacking in adrenal insufficiency Onset: Onset of action is 1 to 2 hours following intravenous administration Duration: 8 to 24 hours Indications: Exacerbation of asthma and COPD, anaphylaxis/acute allergic reactions Contraindications: Known hypersensitivity, Cushing’s Syndrome Precautions: Use caution when administering to patients with diabetes mellitus, pregnancy, liver disease, or signs of systemic infection. Do not administer methylprednisolone preserved with benzyl alcohol to pregnant women, breastfeeding women, or neonates - benzyl alcohol is associated with serious adverse events in this population

Midazolam (VERSED) Class: Benzodiazepine, sedative hypnotic Packaging: 10 mg / 2 ml in (Vial) Dose: Varies on protocol Action: Midazolam is a shorter-acting benzodiazepine central nervous system depressant that produces sedation and lack of recall Onset: IV: 3-5 min // IM: 15-20 min // IN: Unknown Duration: IV: 20-40 min // IM: 1-6 hr // IN: Unknown Indications: Procedural sedation (Cardio version etc.), Combative patients that require chemical sedation, Seizures, Secondary induction agent for RSI, Contraindications: Known benzodiazepine sensitivity, narrow-angle glaucoma Precautions: Pronounce respiratory depression in the elderly

Medication References H - 8

Morphine Class: Opiate, narcotic analgesic Packaging: 4mg / 1 ml (Carpuject Vial) Dose: Varies by protocol Action: Narcotic analgesic, which depresses the central nervous system and sensitivity to pain. Increases venous capacitance, decreases venous return and produces mild peripheral vasodilation. Morphine also decreases myocardial oxygen demand. Onset: IV: Immediate // IM/SC: 15-30 min Duration: IV: Peak effect in 20 minutes // IM/SC: 30-60 min Indications: Pain from an acute traumatic injury, chest pain associated with ACS Contraindications: Known hypersensitivity, hypovolemia, hypotension, head injury, and asthma Precautions: May result in respiratory depression and hypotension (especially in patients who are volume depleted or those with increased systemic vascular resistance)

Naloxone (NARCAN) Class: Narcotic antagonist Packaging: 2mg/2ml (Prefilled Syringe) Dose: Adult 0.4 – 2 mg IV/IO/IM/IN, Peds 0.1 mg/kg Action: Binds the opioid receptor and blocks the effect of narcotics Onset: IV/IO: Less than 2 min // IM/IN: 2 – 10 min Duration: IV/IO: 45 min // IM/IN: >45 min Indications: Respiratory depression associated with narcotic overdose Contraindications: Hypersensitivity to the drug, patients whose respiratory depression is due to non-opioid drugs Precautions: May induce opiate withdrawal in patients who are physically dependent

Medication References H - 8

Normal Saline Class: Isotonic solution Packaging: Prefilled syringe, soft bags Dose: Varies upon protocol Action: Replacement of fluid and electrolytes lost from the intravascular and intracellular spaces Onset: Immediate Duration: Remains in intravascular space for less than an hour Indications: Fluid replacement for hypovolemia, IV access line for drug administration, infusion into saline locks to ensure patency Contraindications: Use caution in patients with rales Precautions: Circulatory fluid volume overload

Nitro-Bid (Nitro Paste) Class: Nitrate, Vasodilator Packaging: 1 g in Folipac® Dose: ½ - 1 inches (1 g /1 in) Action: Direct vasodilator, which acts principally on the venous system although it also produces direct coronary artery vasodilation as a result. There is a decrease in venous return, which decreases the workload on the heart and thus, decreases myocardial oxygen demand Onset: 30 – 60 minutes Duration: 8 – 24 hours Indications: Symptomatic hypertensive crisis Contraindications: Known hypersensitivity, hypotension, and cerebral hemorrhage or head injury. Withhold if the patient has taken Viagra/Levitra within 24 hours and Cialis/Revatio within 48 hours

Medication References H - 8

Precautions: Alcohol will accentuate vasodilating and hypotensive effects. In the event that the patient requires cardioversion or pacing, avoid placing paddles or defibrillator or pacing pads near Nitro patch. It may be necessary to remove Nitro patch and wipe off skin prior to placing paddles or patches before cardioversion or pacing. Nitroglycerin Class: Nitrate, vasodilator Packaging: Tablet in Amber vial Dose: 0.4 mg tablet sublingual Action: Direct vasodilator, which acts principally on the venous system although it also produces direct coronary artery vasodilation as a result. There is a decrease in venous return, which decreases the workload on the heart and thus, decreases myocardial oxygen demand Onset: 1 – 3 minutes Duration: 20 – 30 minutes Indications: Chest pain or discomfort associated with suspected AMI or Angina Pectoris and acute pulmonary edema with hypertension. Contraindications: Known hypersensitivity, hypotension, and cerebral hemorrhage or head injury. Withhold if the patient has taken Viagra/Levitra within 24 hours and Cialis/Revatio within 48 hours Precautions: Use with caution in acute inferior wall MI or right ventricular infarct. Nitro tablets are inactivated by light, air and moisture and must be kept in amber glass containers with tight-fitting lids. Alcohol will accentuate vasodilating and hypotensive effects

Ondansetron (ZOFRAN) Class: Antiemetic Packaging: 4mg / 2ml (Vial) Dose: Adult 4mg IV/IM, Peds 0.1mg/kg max 4mg (must be at least 6 months old) Action: Blocks the effects of serotonin (5HT3) receptor sites peripherally, centrally and its release in the small intestine. Reduces the activity of the vagus nerve from activating the vomiting center in the medulla oblongata Onset: 30 min Duration: 3 – 6 hrs

Medication References H - 8

Indications: Patients experiencing nausea and vomiting Contraindications: Hypersensitivity to Ondansetron or to other similar drugs. Precautions: Liver disorders, Long QT syndrome (heart problems), and Phenylketonuria

Promethazine (Phenergan®) Class: Antiemetic Packaging: 25 mg / ml (Vial) Dose: Adult 12.5 mg IV, 25 mg IM. Ped: 0.25 mg / kg IV (max 25 mg), 0.5 mg IM (max 25 mg) Action: Administered to prevent and control nausea, vomiting, and motion sickness. It is also used as a sedative and to potentiate the effects of analgesics Onset: IV: 5 minutes // IM : 20 minutes Duration: 4 – 6 hours Indications: Nausea, vomiting, and motion sickness. To potentiate the effects of analgesics; to induce sedation. Contraindications: Hypersensitivity to phenothiazines, nursing mothers, newborn or premature infants, acutely ill or dehydrated children. Precautions: Patients with impaired hepatic function, cardiovascular disease, asthma, acute or chronic respiratory impairment (particularly in children), hypertension; elderly or debilitated patients

Quelicin (Succinylcholine) Class: Depolarizing Neuromuscular Blocker Packaging: 200 mg / 10 ml (Vial) Dose: 1.5 mg / kg – (Max of 200 mg) IV/IO Action: Depolarizing skeletal muscle relaxant; no effect on consciousness or pain Onset: 30 – 60 seconds Duration: 2 – 10 minutes Indications: RSI Contraindications: Hypersensitivity to the drug. Hyperkalemia. Malignant hyperthermia. Narrow-angle glaucoma. Major burns greater than 16 hours and up to 6

Medication References H - 8 months. Penetrating eye injuries. Chronic paralysis. Neuromuscular disorders such as Multiple Sclerosis and Muscular Dystrophy Precautions: Increased ocular pressure. Burn patients. Organophosphate poisoning. Hyperthermia. Allergic reactions / Anaphylaxis may occur

Medication References H - 8

Racemic Epinephrine Class: Sympathomimetic Packaging: (made by combining 1 mg of Epinephrine 1:1000 with 2.5 – 3 cc normal saline ) Dose: Adult/Ped 1 mg Epinephrine 1:1000 in 2.5 – 3 ccs normal saline Nebulized Action: Racemic epinephrine stimulates both alpha- and beta-adrenergic receptors, with a slight preference for the beta2 receptors in the lungs. This results in bronchodilation and a decrease in mucus secretion. It also has some effect in relieving the subglottic edema Onset: Within 5 min Duration: 30 minutes – 2 hours (Peak: 5 – 20 minutes) Indications: Subglottic edema in croup (laryngotracheobronchitis) Contraindications: Known hypersensitivity, epiglottitis. Precautions: Tachycardia and dysrhythmias may develop

Rocuronium (Zemuron) Class: Non-depolarizing Neuromuscular Blocker Packaging: 10 mg / 10 ml (Vial) Dose: 1 mg / kg – (Max of 100 mg) IV/IO Action: Non-depolarizing skeletal muscle relaxant; cholinergic receptor antagonist, inhibits depolarization Onset: 1 – 2 minutes Duration: 30 - 60 minutes Indications: Intubated patients that require a long-acting skeletal muscle relaxant Contraindications: Hypersensitivity. Neuromuscular disease. Lack of waveform ETCO2 Precautions: Allergic reactions / Anaphylaxis may occur. Increased ocular pressure. Hepatic disease. Patients with ascites may require larger dose to assure complete block

Medication References H - 8

Sodium Bicarbonate Class: Electrolyte Packaging: 50 mEq per 50 ml (Prefilled Syringe) Dose: 1 mEq/kg IV/IO for Adults and Peds Action: An alkalizing agent used to buffer acids present in the body during and after severe hypoxia. Bicarbonate combines with excess acids (usually lactic acid) present in the body to form a weak, volatile acid. This acid is broken down into CO2 and H2O. Sodium bicarbonate is effective only when administered with adequate ventilation and oxygenation Onset: Immediate Duration: Dependent upon degree of acid/base imbalance Indications: Metabolic acidosis due to salicylate (Aspirin) overdose, barbiturate overdose, tricyclic antidepressant overdose, hyperkalemia, severe ketoacidosis, cardiac arrest, shock, physostigmine toxicity, methanol toxicity, ethylene glycol toxicity. Contraindications: Congestive heart failure, alkalotic states Precautions: Can cause metabolic alkalosis

Thiamine Class: Vitamin (B1) Packaging: 200 mg / 2 ml (Vial) Dose: Adult 50 − 100 mg given slow IV/IM. Ped 10 − 25 mg given slow IV/IM Action: Required for the conversion of glucose into energy and for the conversion of pyruvic acid to acetyl-coenzyme-A Onset: Immediate Duration: Dependent upon degree of deficiency Indications: Coma of unknown origin especially if alcohol involved, delirium tremors Contraindications: Known hypersensitivity Precautions: Hypotension, burning at IV site

Medication References H - 8

Vecuronium (Norcuron) Class: Non-depolarizing Neuromuscular Blocker Packaging: 10 mg / 10 ml (Vial) Dose: 0.1 mg / kg – (Max 10 mg) IV/IO Action: Non-depolarizing skeletal muscle relaxant; cholinergic receptor antagonist, inhibits depolarization Onset: 3 – 5 minutes Duration: 20 – 35 minutes Indications: Intubated patients that require a long-acting skeletal muscle relaxant Contraindications: Hypersensitivity. Neuromuscular disease. Lack of waveform ETCO2 Precautions: Allergic reactions / Anaphylaxis may occur

Medication References H - 8

Wilson County Emergency Management Agency Protocol Manual Drug References

Narcotics

Alenta Alfentanil hcl Astramorph.PF Buprenex Buprenorphine.hcl Butorphanol.Tartrate Codeine.Phosphate Codeine.Sulfate Codoxy Dalgan Darvon.pulvules Demerol Dezocine Dilaudid Dilaudid HP Diprivan Dolene Dolophine.hcl Duramorph Fenoprofen Fentanyl Fentanyl.Citrate Fentanyl.Transdermal Hydromorphone.hcl Ingumorph 200, 500 Innovar Levo-dromoran Levorphanol Tartrate Meperidine.hcl Methadone hcl Methadone hcl Intensol Morphine Sulfate MS Contin MSIR Nalbuphine hcl Nalfon Nubain OMS Concentrate Oramorph SR Oxycondone Oxymorphone hcl Pentazocine hcl Pentazocine Lactate Propoxyphene hcl Percodan Propoxyphene hcl Propoxyphene Napsylate RMS Roxanol Roxanol Rescudose Roxanol SR Roxicodone Stadol Sublimaze Talwin Tylox

Drug Reference - Narcotics Page 1 of 1 H - 9 Wilson County Emergency Management Agency Emergency Pediatric Drug Dosages

GRAY GRAY GRAY GRAY GRAY GRAY PINK PINK RED RED PURPLE PURPLE Weight guidelines 3 kg 3 kg 4 kg 4 kg 5 kg 5 kg 6 & 7 kg 6 & 7 kg 8 & 9 kg 8 & 9 kg 10 & 11 kg 10 & 11 kg Age guidelines Newborn Newborn Newborn Newborn Newborn Newborn up to 6 m/o up to 6 m/o ~ 9 mo ~ 9 mo ~ 1 y/o ~ 1 y/o

Adenocard (3mg/ml) (1st) 0.3 mg 0.1 ml 0.4 mg 0.13 ml 0.5 mg 0.17 ml 0.6 mg 0.2 ml 0.8 mg 0.27 ml 1 mg 0.33 ml Adenocard (3mg/ml) (2nd) 0.6 mg 0.2 ml 0.8 mg 0.27 ml 1 mg 0.34 ml 1.2 mg 0.4 ml 1.6 mg 0.53 ml 2 mg 0.67 ml Amiodarone (150mg/3ml) 15 mg 0.3 ml 20 mg 0.4 ml 25 mg 0.5 ml 30 mg 0.6 ml 40 mg 0.8 ml 50 mg 1 ml Atropine (1mg/10ml) 0.1 mg 1 ml 0.1 mg 1 ml 0.1 mg 1 ml 0.12 mg 1.2 ml 0.16 mg 1.6 ml 0.2 mg 2 ml Calcium Chloride 10% 60 mg 0.6 ml 80 mg 0.8 ml 100 mg 1 ml 120 mg 1.2 ml 160 mg 1.6 ml 200 mg 2 ml Dextrose 10% 0.6 Gm 6 ml 0.8 Gm 8 ml 1 Gm 10 ml Dextrose 25% 1.5 Gm 6 ml 2 Gm 8 ml 2.5 Gm 10 ml 3 Gm 12 ml 4 Gm 16 ml 5 Gm 20 ml Epi 1:10,000 (1mg/10ml) 0.03 mg 0.3 ml 0.04 mg 0.4 ml 0.05 mg 0.5 ml 0.06 mg 0.6 ml 0.08 mg 0.8 ml 0.1 mg 1 ml Epi 1:1,000 (1mg/ml) ETT 0.3 mg 0.3 ml 0.4 mg 0.4 ml 0.5 mg 0.5 ml 0.6 mg 0.6 ml 0.8 mg 0.8 ml 1 mg 1 ml Lidocaine (100mg/5ml) 3 mg 0.15 ml 4 mg 0.2 ml 5 mg 0.25 ml 6 mg 0.3 ml 8 mg 0.4 ml 10 mg 0.5 ml Magnesium (1Gm/2ml) 150 mg 0.3 ml 200 mg 0.4 ml 250 mg 0.5 ml 300 mg 0.7 ml 400 mg 0.8 ml 500 mg 1 ml Soduim Bi Carb (4.2%) 1.5 mEq 3 ml 2 mEq 4 ml 2.5 mEq 5 ml 3 mEq 6 ml 4 mEq 8 ml 5 mEq 10 ml Valium (10mg/2ml) IV 0 .3 mg 0 .06 mg 0 .4 mg 0 .08 ml 0 .5 mg 0 .1 ml 1 .2 mg 0.24 ml 1.6 mg 0.3 ml 2 mg 0.4 ml Valium (10mg/2ml)RECTAL 1.5 mg 0.3 ml 2 mg 0.4 ml 2.5 mg 0.5 ml 3 mg 0.6 ml 4 mg 0.8 ml 5 mg 1.0 ml Versed (10mg/2ml) IV/IO 0.3 mg 0.06 ml 0.4 mg 0.08 ml 0.5 mg 0.1 ml 0.6 mg 0.12 ml 0.8 mg 0.16 ml 1 mg 0.2 ml Versed (10mg/2ml) IN 0.6 mg 0.3 ml 0.8 mg 0.16 ml 1 mg 0.2 ml 1.2 mg 0.25 ml 1.6 mg 0.32 ml 2 mg 0.4 ml

Color (Broselow tape) YELLOW YELLOW WHITE WHITE BLUE BLUE ORANGE ORANGE GREEN GREEN Weight guidelines 12 - 14 kg 12 - 14 kg 15 - 18 kg 15 - 18 kg 19 - 22 kg 19 - 22 kg 24 - 28 kg 24 - 28 kg 30 - 36 kg 30 - 36 kg Age guidelines ~ 2 y/o ~ 2 y/o 4 y/o 4 y/o 6 y/o 6 y/o 8 y/o 8 y/o 10 y/o 10 y/o

Adenocard (3mg/ml) (1st) 1.2 mg 0.4 ml 1.5 mg 0.5 ml 1.9 mg 0.63 ml 2.4 mg 0.8 ml 3 mg 1 ml Adenocard (3mg/ml) (2nd) 2.4 mg 0.8 ml 3 mg 1 ml 3.8 mg 1.3 ml 5.4 mg 1.8 ml 6 mg 2 ml Amiodarone (150mg/3ml) 60 mg 1.2 ml 75 mg 1.5 ml 95 mg 1.9 ml 120 mg 2.4 ml 150 mg 3 ml Atropine (1mg/10ml) 0.24 mg 2.4 ml 0.3 mg 3 ml 0.38 mg 3.8 ml 0.48 mg 4.8 ml 0.5 mg 5 ml Calcium Chloride 10% 240 mg 2.4 ml 300 mg 3 ml 380 mg 3.8 ml 480 mg 4.8 ml 600 mg 6 ml Dextrose 25% 6 Gm 24 ml 7.5 Gm 30 ml 9.5 Gm 38 ml 12 Gm 48 ml NA NA Dextrose 50% NA NA NA NA NA NA NA NA 16.5 Gm 33 ml Epi 1:10,000 (1mg/10ml) 0.12 mg 1.2 ml 0.15 mg 1.5 ml 0.19 mg 1.9 ml 0.27 mg 2.7 ml 0.3 mg 3 ml Epi 1:1,000 (1mg/ml) ETT 1.2 mg 1.2 ml 1.5 mg 1.5 ml 1.9 mg 1.9 ml 2.4 mg 2.4 ml 2.5 mg 2.5 ml Lidocaine (100mg/5ml) 12 mg 0.6 ml 15 mg 0.75 ml 19 mg 0.95 ml 24 mg 1.2 ml 30 mg 1.5 ml Magnesium (1Gm/2ml) 600 mg 1.2 ml 750 mg 1.5 ml 950 mg 1.9 ml 1200 mg 2.4 ml 1500 mg 3.1 ml Soduim Bi Carb (8.4%) 12 mEq 12 ml 15 mEq 15 ml 19 mEq 19 ml 24 mEq 24 ml 30 mEq 30 ml Valium (10mg/2ml) IV 2.5 mg 0.5 ml 3.0 mg 0.6 ml 4 mg 0.8 ml 4 mg 0.8 ml 4 mg 0.8 ml Valium (10mg/2ml)RECTAL 5 mg 1.0 ml 5 mg 1.0 ml 5 mg 1.0 ml 5 mg 1.0 ml 5 mg 1.0 ml Versed (10mg/2ml) IV/IO 1.2 mg 0.24 ml 1.5 mg 0.3 ml 2 mg 0.4 ml 2.5 mg 0.5 ml 3.5 mg 0.7 ml Versed (10mg/2ml) IN 2.5 mg 0.5 ml 3 mg 0.6 ml 4 mg 0.8 ml 4 mg 0.8 ml 4 mg 0.8

Adenocard (3mg/ml) regardless of 6mg/2ml or 12 mg/4ml prefilled syringes The drug dosages are based on the setup of Wilson County EMA. Version 4 Revised: 9/22/2016 Drug Reference - WEMA Chart Page 1 of 1 H - 13 Wilson County Emergency Management Agency Protocol Manual Drug Reference

Tricyclics

Amitriptyline hcl Amoxapine Anafranil Asendin Aventyl hcl Clomipramine hcl Desipramine hcl Doxepin hcl Elavil Endep Enovil Imipramine hcl Janimine Norpramine Nortriptyline hcl Pamelor Pertofrane Protriptyline hcl Sinequan Surmontil Tofranil Trimipramine Maleate Trisoralen Vivactil

Drug Reference - Tricyclics Page 1 of 1 H - 14 Drug Guide

WEMA Protocol: Fever / Infection (C-6.1) 15 mg / kg PO Pediatric Seizure (C-13) Max Dose: 500 mg Indications /Contraindications: One time dose Fever > 100.4 Post Febrile Seizure Avoid in PT's with severe liver disease

Adenosine 3 mg / ml (Adenocard)

WEMA Protocol: SVT, PSVT (B-9)

Indications/Contraindications: SVT, PSVT Avoid in high degree blocks,VT, and Sick Sinus

Albuterol 2.5 mg / 3 ml Beta-Agonist

WEMA Protocol: Respiratory Distress (C-12) 2.5 mg in 3 cc's NS 2.5 mg in 3 cc's NS Nebulized Nebulized Indications/Contraindications: Bronchospasm, COPD, Asthma May repeat twice as May repeat twice as Avoid in tachydysrhythmias long as HR is < 150 long as HR is < 200

WEMA Drug Guide 2016 H-15 Drug Guide

This document serves as a reference for medications included in the 2015 WEMA Protocols. Utilize the individual protocols and standardized medication guides for all dosing. Drug Adult Pediatric Amiodirone 50 mg / ml V-fib / Pulseless V-Tach V-fib / Pulseless V-Tach (Cordarone) 300 mg Bolus IV / IO 5 mg / kg slow IV push A second dose of 150 mg for WEMA Protocol: recurrent events V-Fib (B-11) V-Tach with a Pulse V-Tach (B-12) PVC (B-7) V-Tach with a Pulse 150 mg over 10 minutes 5 mg / kg infused over 30 Indications/Contraindications: minutes V-Fib PVC's Wide Complex Tachycardia's 150 mg over 10 minutes PVC's (as defined in protocol) Use the "Right Dose" Book or Avoid in heart block's and WEMA infusion sheet to profound bradycardia's

Aspirin (ASA) 81mg / tab 81 mg chewable tablet WEMA Protocol: Chest Pain / STEMI (C-4) PO

Indications/Contraindications: Desired dose: 324 mg Chest pain

Atropine 0.1 mg / ml Bradycardia Reflexive Bradycardia 0.02 mg/kg IV / IO Minimum of 0.1 mg WEMA Protocol: 0.5-1 mg IV/IO every 3-5 mins up to 0 .04 mg/kg or 3 mg total dose Bradycardia (B-4) Organophosphate poisoning Organophosphate poisoning Organophosphate poisoning 0.05 mg/kg IV / IO until vital (D-11) signs improve 2 mg IV / IO every 5 mins for See Color Coded Chart Symptomatic bradycardia or moderate SLUDGE to reduce the effects of Calcium Chloride 10% Cardiac Arrest Cardiac Arrest 500 - 1000 mg bolus IV / IO 20 mg / kg bolus IV / IO WEMA Protocol: 100 mg / ml PEA / Asystole This is diagnostic specific as This is diagnostic specific as Drug ingestion described in the protocols described in the protocols Crush Indications/Contraindications: Known CCB OD, Crush injuries See Color Coded Chart Severe Hyperkalemia Digitalis toxicity

WEMA Drug Guide 2016 H-15 Drug Guide

WEMA Protocol: Blood sugar 40-80: 2 ml / kg Hypoglycemia (D-9) Dextrose 50% Blood sugar < 40: 4 ml / kg Indications/Contraindications: Dextrose 25% Hypoglycemia 2 months - 8 years Titrate to a blood glucose of Blood sugar 40-80: 12 .5g 70 mg/dl in patients with Blood Sugar 40-80: 1 ml / kg increased ICP Blood sugar < 40: 25g

Dextrose 5% Not for use as fluid replacement or volume IV solution Possible maintenance expansion infusion for hypoglycemic WEMA Protocol: neonates. Various drug mixtures Not for use as fluid Various amount needed for Contact Vanderbilt Pediatric replacement or volume ED for orders and dosing. expansion different drug mixtures

Diazepam 5 mg / ml Neonate < 1 month - (IV/IO) IV / IO ONLY 0.1 mg/kg (Up to 1 mg) (Valium) May repeat once 5 mg slow push WEMA Protocol: 1 month - 5 years - (IV/IO) Seizures (C-13) May repeat once 0.2 mg/kg (Up to 2.5 mg) Max total dose: 10 mg May repeat once Indications/Contraindications: 5 - 12 years - (IV/IO) Seizures 0.3 mg/kg (Up to 4 mg) Head Injury, Hypotension, May Repeat Once Acute glaucoma

Diltiazem 1 mg / ml Initial Rx (Cardizem) 0.25 mg/kg slow IV bolus

WEMA Protocol: If No Change A-Fib & A-flutter (B-2) 0.25 mg/kg slow IV bolus

Indications/Contraindications: A-fib with RVR or A-flutter Refer to procedure I-5.1 for Use EXTREME caution in instructions on delivery patients taking beta blockers Can not be given in the BP, Heart block or failure same line as Lasix

WEMA Drug Guide 2016 H-15 Drug Guide

WEMA Protocol Chest Pain (C-4) < 6 months - 0 .1 mg/kg Pain management (E-13) CHF (C-4.1) Sickle Cell Anemia (C-14) > 6 months - 0 .2 mg/kg 2 - 4 mg IV / IO / IM Indications/Contraindications Ischemic chest pain Max single dose: 4 mg Moderate to severe pain CHF IV / IO / IM Pulmonary edema Hypotension Respiratory depression

Naloxone 1 mg / ml 0.5 mg increments 0.1 mg / kg (Narcan) Up to 2 mg Max single dose: 2 mg WEMA Protocol Various IV / IO / IN / IM IV / IO / IN / IM Contraindications/Indications Absolute Maximum dose 4 mg Absolute Maximum dose 4 mg Suspected opioid or other narcotic overdose Normal Saline Varies Varies

Standard isotonic fluid for volume replacement Normal bolus - 20 ml / kg Normal bolus - 20 ml / kg For use when a bolus, flush, mix is needed Nitroglycerin (NTG) 0.4 mg tablet SL 0.4 mg / tab & Paste WEMA Protocol For Chest Px & CHF Chest pain (C-4) May repeat twice CHF (C-4.1) Depending on BP HTN Crisis (C-8) Indications Contraindication Chest pain Pulmonary edema HTN crisis Hypotension Use of ED drugs Use Extreme caution if an Suspect stroke Inferior MI is suspected

WEMA Drug Guide 2016 H-15 Drug Guide

WEMA Protocol: 25 mg IV / IO Allergic reaction (C-2) Anaphylaxis (C-2.1) 50 mg IM Mast cell activation (C-10) 0.1 mg / kg IV / IO / IM Indications/Contraindications Uticaria and / or itching Mast Cell Activation Anaphylaxis Mast cell activation 50 mg IV / IO / IM Acute Asthma

Dopamine 2-20 mcg / kg per min IV or 2-20 mcg / kg per min IV or 800:1 solution IO - Titrate to affect IO - Titrate to affect

WEMA Protocol: Use the "Right Dose" Book Use the "Right Dose" Book Bradycardia (B-4) Septic Shock (E-18) Starting dose: 5 mcg / kg / min Neurogenic shock (E-17) Epi drip is preferred for Post resuscitation (B-6) pediatrics in refractory Cardiac Dose bradycardia Indications/Contraindications Hypotension due to 5-10 mcg / kg / min Starting dose: 5 mcg / kg / min decreased cardiac output, septic shock, post resuscitation, & symptomatic Vasopressor Dose bradycardia Ventricular arrhythmias, sulfite 10-20 mcg / kg / min

Epinephrine 1 mg / ml Anaphylaxis Anaphylaxis 1:1000 solution 0.01 mg/kg IM - Max .5 0.01 mg/kg IM mg Max 0 .3 mg WEMA Protocol: Asthma Anaphylaxis (C-2.1) Asthma 0.01 mg/kg IM Asthma (C-12) 0.3 mg IM Croup (C-5) Max 0 .3 mg Mast Cell (C-10) Croup Indications/Contraindications Mast Cell Activation 1 mg in 3 cc's NS Bronchospasm 0.3 mg IM If severe first dose can Anaphylactic reactions every 5 mins as needed be 3 mg Mast Cell activation (systemic) Nebulized

WEMA Drug Guide 2016 H-15 Drug Guide

WEMA Protocol: 1 mg bolus IV / IO 0.01 mg/kg IV / IO Cardiac Arrest (Section B) Every 3-5 mins Every 3-5 mins Anaphylaxis (C-2.1) Bradycardia (Pediatric) (B-4)

Indications/Contraindications Cardiac Arrest Life Threatening Life Threatening Life Threatening Anaphylaxis Anaphylaxis Anaphylaxis Pediatric symptomatic bradycardia (despite O2) 0.3 - 0 .5 mg slow bolus 0.01 mg/kg IV / IO None during life threatening events IV/IO Up to 0 .3 mg

Epinephrine Bradycardia Use the "Right Dose" Book Drip 2-10 mcg / min Titrate to effect Bradycardia WEMA Protocol: 2-10 mcg / min Bradycardia (B-4) Titrate to effect Mast Cell (C-10) Mast Cell Activation Indications/Contraindications 4-10 mcg / min Post Arrest Hypotension Symptomatic Bradycardia Titrate to effect 2-10 mcg / min Mast Cell Activation Titrate to effect Post Arrest Hypotension

Fentanyl 50 mcg / ml Moderate Pain < 12 y/o (Sublimaze) 1 mcg / kg - IV / IO 1 mcg / kg - IN / IM Moderate Pain WEMA Protocol: 100 mcg max single 0.5 mcg / kg - IV / IO Various trauma protocols (E) dose 0.5 mcg / kg - IN / IM Sickle Cell (C-10) 50 mcg max single dose Chest Pain (C-4) Severe Pain Protocol Specific Severe Pain Indications/Contraindications 2 mcg / kg - IV / IO Protocol Specific 1 mcg / kg - IV / IO Traumatic injury 2 mcg / kg - IN / IM Severe pain 1 mcg / kg - IN / IM Chest pain with morphine 200 mcg max single 100 mcg max single dose allergy dose

WEMA Drug Guide 2016 H-15 Drug Guide

This document serves as a reference for medications included in the 2015 WEMA Protocols. Utilize the individual protocols and standardized medication guides for all dosing. Drug Adult Pediatric Glucose (Oral) < 2 y/o 15 grams / pack Carefully massage a small WEMA Protocol amount of the gel onto the Hypoglycemia (C-9) gums of the child; be cautious of biting. Repeat Indications/Contraindications 1 pack / (15 grams) as needed Hypoglycemia Unable to swallow Unable to follow commands > 3 y/o Absent gag reflex 1 pack (15g) while closely monitoring the child

Ipratropium .02% (Atrovent) 0.5 mg / 2 .5 ml

WEMA Protocol 0.5 mg in 2.5 cc's NS 0.5 mg in 2.5 cc's NS Respiratory Distress (C-12)

Indications/Contraindications Nebulized Nebulized Asthma & COPD Bronchospasm Glaucoma

WEMA Drug Guide 2016 H-15 Drug Guide

WEMA Protocol 4 mg IV / IM 0.1 mg/kg IV / IM Various May repeat once May repeat once Indications/Contraindications Nausea (C-11) Vomiting

Promethazine 25 mg / ml (Phenergan) 12 .5 mg IV 0.25 mg/kg IV or (Max 12.5 mg) WEMA Protocol 25 mg IM Various or 0.5 mg/kg IM Indications/Contraindications (Max 25 mg) Nausea (C-11) Vomiting Use cautiously with pediatrics and the elderly If given IV, it must be If given IV, it must be Be cautious of the sedative diluted in 5-10 cc's NS diluted in 5-10 cc's NS effect flush and given very flush and given very < 2 y/o slowly slowly Sodium Bicarbonate < 1 month use 4.2% (NaHCO3) 1 MeQ / ml

WEMA Protocol Cardiac Arrest > 1 month use 8.4% Cardiac arrest (Section B) 1-1 .5 mEq / kg IV / IO Poisoning / Ingestion (D-10) Cardiac Arrest Indications/Contraindications 1 mEq / kg IV / IO Metabolic acidosis due to cardiac arrest Tricyclic OD Tricyclic OD Tricyclic OD Contact Vanderbilt Can not mix with various Contact medical control pediatrics for orders medications in tubing for orders Inadequate ventilation See Color Coded Chart

WEMA Drug Guide 2016 H-15 Drug Guide

This document serves as a reference for medications included in the 2015 WEMA Protocols. Utilize the individual protocols and standardized medication guides for all dosing. Drug Adult Pediatric Ketamine (50mg/ml) Severe Pain Severe Pain (Ketalar) As described by protocol 0.5 mg / kg - IV / IO WEMA Protocol: Up to 100 mg Severe pain management May repeat twice (Various) (E-13) Not to exceed 300 mg Thermal Burn's (E-5) Amputation's (E-3) OR Extremity extrication (E-6.1) 1 mg / kg - IN / IM Indications/Contraindications Severe pain Up to 150 mg Procedural Sedation needed May repeat twice Must Have access to airway Not to exceed 450 mg Must be able to suction patient Hx of CHF Hx of CAD Extremity Extrication Extremity extrication Use caution if TBI present 1 mg / kg - IV / IO 1 mg / kg - IV / IO Hypertensive crisis Up to 40 mg Relative Hypertension Up to 200 mg Systolic > 180 Diastolic > 130 Any Acute Ischemic event 1.5 mg / kg - IN / IM 1.5 mg / kg - IN / IM Herniation Syndrome Up to 225 mg Up to 60 mg Cushings Syndrome

Can not be used to Can not be used to

Ketorolac 30 mg / ml (Toradol)

WEMA Protocol Pain Management - General 30 mg IV (G-8)

Indications/Contraindications OR Pain due to kidney stones Back pain 60 mg IM Muscle Sprain / Strain Migraine Pregnancy Renal insufficiency Hypovolemia

WEMA Drug Guide 2016 H-15 Drug Guide

WEMA Protocol Various 20 ml/kg Bolus 20 ml/kg Bolus Indications/Contraindications Hypovolemia due to blood loss Volume replacement

Lidocaine 2% Ventricular dysrhythmias Ventricular dysrhythmias Single Dose (20 mg / ml) 1 - 1 .5 mg / kg 1 mg / kg

WEMA Protocol PVC's PVC's Cardiac (Section B) 1 - 1 .5 mg / kg 1 mg / kg IO procedure (I-21) V-fib / Pulseless VT Indications/Contraindications V-fib / Pulseless VT Ventricular dysrhythmias 1 - 1 .5 mg / kg 1 mg / kg V-fib / Pulseless VT Local anesthetic for IO inf. Anesthetic for IO infusion Anesthetic for IO infusion 1/2 dose for patients > 70 See I-21 for procedure See I-21 for procedure 1/2 dose for patient w/ history 40 mg Initially 0.5 mg/kg Initially (Max 40) of hepatic disease 20 mg subsequently half initial dose subsequently AV block Bradycardia Max dose as an Max dose as an antiarrhythmic antiarrhythmic 3 mg / kg 3 mg / kg See Color Coded Chart Lidocaine Drip 4 mg / ml solution Use the "Right Dose" Book WEMA Protocol Cardiac (B-7) & (B-12) 1 - 4 mg / min Indications/Contraindications Maintenance drip post maintenance infusion 20-50 mcg / kg / min dysrhythmia conversion Same as single dose

WEMA Drug Guide 2016 H-15 Drug Guide

This document serves as a reference for medications included in the 2015 WEMA Protocols. Utilize the individual protocols and standardized medication guides for all dosing Drug Adult Pediatric Magnesium Sulfate Asthma / COPD Asthma 10% 500 mg / ml 1-2 grams over 10 mins 25 - 50 mg/kg over 20 mins See drip procedure WEMA Protocol Torsade's de pointes Respiratory Distress (C-12) 1-2 grams IV / IO Torsade's de pointes Cardiac (Section B) Infuse over 10 mins 25 - 50 mg/kg IV / IO Eclampsia w/ seizures (F-4) Infuse over 20 mins Indications/Contraindications Cardiac Arrest Severe Asthma 1-2 grams IV / IO Cardiac Arrest COPD Slow push over 2 mins 25 - 50 mg/kg IV / IO Torsade's de pointes Slow push over 2 mins Hypokalemia (Arrest) Eclampsia w/ seizures Hypomagnesemia 1-2 grams over 10 mins Max dose of 2 grams Eclampsia w/ seizures AV Block Methylprednisolone One time dose (Solu-Medrol) 62.5 mg / ml 125 mg IV / IM WEMA Protocol Anaphylaxis (C-2.1) Asthma (C-12) If small in stature, sensitive Contact Medical control to steroids, on chronic Indications/Contraindications steroid therapy or diabetic Acute asthma attack Acute anaphylactic reaction Use w/ caution in patients with 62 .5 mg active infections

Midazolam Seizure All Pediatrics - (IV/IO/IM) (Versed) 5 mg / ml 5 mg IV / IO / IN / IM 0.1 mg/kg IV / IO / IM Max Dose 6 mg DO NOT REPEAT WEMA Protocol General Sedation Sedation in various protocols 2-5 mg IV / IO / IN / IM Seizure (C-13) 1 - 5 Months - (IN) 0.2 mg/kg IN Indications/Contraindications Mind Altering Drugs Max dose: 3 mg Seizure Activity 5-10 mg IV / IN / IM DO NOT REPEAT Required sedation Be cautious w/ hypotension 5 months - 12 years - (IN) Will cause significant Resp. The max dose varies by protocol. 0.2 mg/kg IN depression in elderly Max dose: 4 mg < 1 month old May Repeat Once Pregnancy Max Total dose: 8 mg

WEMA Drug Guide 2016 H-15 Drug Guide

This document serves as a reference for medications included in the 2015 WEMA Protocols. Utilize the individual protocols and standardized medication guides for all dosing. Drug Adult Pediatric Thiamine 100 mg / ml One time dose WEMA Protocol AMS / Unconscious (C-3) Hypoglycemia (C-9) Seizure (C-13) 100 mg IV / IO Indications/Contraindications Wernicke-Korsakoff syndrome Malnourished Chronic alcoholism

WEMA Drug Guide 2016 H-15 WEMA Drug List - 2016 Drugs: Generic Name Drugs: Trade Name Acetaminophen TYLENOL Adenosine ADENOCARD Albuterol VENTOLIN Amiodirone CORDARONE Aspirin (ASA) ASA Atropine N/A Calcium chloride 10% N/A Dextrose 10%, 25%, 50% N/A Dextrose 5% IV solution N/A Diazepam VALIUM Diltiazem CARDIZEM Diphenhydramine BENADRYL Dopamine Drip 800 mcg / ml INTROPIN Epi 1:1000 ADRENALIN Epi 1:10000 ADRENALIN Fentanyl SUBLIMAZE Glucose (oral) N/A Ipatropium Bromide 0.02% ATROVENT Ketamine KETALAR Ketorolac TORADOL Lactated Ringers N/A Lidocaine 2% XYLOCAINE Lidocaine Drip 4 mg / ml XYLOCAINE Magnesium Sulfate 10% N/A Methylprednisolone SOLU-MEDROL Midazolam VERSED Morphine Sulfate N/A Naloxone NARCAN Normal Saline N/A Nitro-paste (NTG) (TD Paste) NITRO-BID Ntroglycern (NTG) (SL Tab) N/A Ondansetron N/A Promethizine PHENERGEN Sodium Bicarb N/A Thiamine VITAMIN B1

WEMA Drug Guide 2016 H-15