Chapter 12 Emergency Medications. National EMS Education Standard Competencies Pharmacology...
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Transcript of Chapter 12 Emergency Medications. National EMS Education Standard Competencies Pharmacology...
Chapter 12Chapter 12
Emergency Medications
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Pharmacology
Integrates comprehensive knowledge of pharmacology to formulate a treatment plan intended to mitigate emergencies and improve the overall health of the patient.
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Emergency Medications
• Names
• Effects
• Indications
• Routes of administration
• Dosages for the medications administered
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Emergency Medications (cont’d)
• Actions
• Contraindications
• Complications
• Side Effects
• Interactions
IntroductionIntroduction
• Paramedics must have a comprehensive understanding of all medications they might administer.− Pharmacology is one of the more difficult
subjects to master.
IntroductionIntroduction
• Paramedics have to make quick decisions about:− When to administer medications
− What medications to administer
− When administering certain medications would be harmful to the patient
IntroductionIntroduction
• Pharmacology is constantly changing.− Stay up to date on the latest pharmacologic
information.
• State and regional EMS systems have the right to include medications and indications.− Always follow local protocols.
AHA Classification of Recommendations and Level
of Evidence
AHA Classification of Recommendations and Level
of Evidence
• Class I− A treatment should be administered.
• Class IIa− It is reasonable to administer treatment.
• Class IIb− Treatment may be considered.
AHA Classification of Recommendations and Level
of Evidence
AHA Classification of Recommendations and Level
of Evidence
• Class III− Treatment should NOT be administered.
− It is harmful, not helpful.
• Class Indeterminate− Research is either beginning or continuing on
this treatment.
− Cannot be recommended for or against
Pregnancy Category Ratings for Drugs
Pregnancy Category Ratings for Drugs
• Category A− Possibility of fetal harm appears to be remote
• Category B− Either:
• Animal studies have not demonstrated a fetal risk but there are no controlled studies in women or
• Animal reproductive studies have shown an adverse effect that was not confirmed in controlled studies on women in the first trimester
Pregnancy Category Ratings for Drugs
Pregnancy Category Ratings for Drugs
• Category C− Drugs in this category should be given only if
the potential benefit justifies the risk to the fetus.
• Category D− There is positive evidence of human fetal risk,
but the benefits for pregnant women may be acceptable despite the risk.
Pregnancy Category Ratings for Drugs
Pregnancy Category Ratings for Drugs
• Category X− The risk of using the drug in pregnant women
clearly outweighs any possible benefit.
− The drug is contraindicated in women who are or may become pregnant.
Federal “Controlled Substance Act of 1970” Schedule Summary
Federal “Controlled Substance Act of 1970” Schedule Summary
• The legal foundation of the government’s fight against abuse of drugs and other substances.− Consolidation of many laws regulating the
manufacture/distribution of controlled substances
− Enforced by the DEA
Radio CommunicationsRadio Communications
• Become familiar with terminology related to medications and medication administration.
• Be familiar with common medical abbreviations.
Radio CommunicationsRadio Communications
Radio CommunicationsRadio Communications
Drug Dosage CalculationsDrug Dosage Calculations
• Desired dose− Quantity of a medication that is to be administered
• Concentration− Amount of medication that is present in vial
• Volume − Amount of fluid medication is dissolved in
• Yield− The amount of drug in 1 mL
Medication ListingsMedication Listings
• Name of medication− And other common names
• Class− How the medication is classified compared to
other medications
Medication ListingsMedication Listings
• Mechanism of action− The way a medication produces the intended
response
• Indications− Circumstance that shows cause or warning of
disease
• Contraindications− Any condition that renders some particular line
of treatment improper or undesirable
Medication ListingsMedication Listings
• Adverse reaction/side effects− An abnormal or harmful effect to an organism
caused by exposure to a chemical
• Drug interactions− Any potential effects a medication may have
when administered with or in the presence of something else in the patient’s system
Medication ListingsMedication Listings
• How supplied− How the manufacturer packages the medication
for distribution and sale
• Dosage and administration− Typical or average volume of the medication to
be administered and the route of introduction
Medication ListingsMedication Listings
• Duration of action− Onset
− Peak effect
− Duration
• Special considerations
Activated Charcoal (EZ-Char, Actidose, Liqui-Char)
Activated Charcoal (EZ-Char, Actidose, Liqui-Char)
• Mechanism of action− Absorbs toxic
substances from the gastrointestinal tract
• Indications− Most oral poisonings/
medication overdoses
• Contraindications− Oral administration to
comatose patients
• Adverse reactions− If aspirated, can
induce fatal form of pneumonitis
− Bowel obstruction
• Considerations− Mix contents well
before administration.
− Does not absorb cyanide, lithium, iron, lead, or arsenic
Adenosine (Adenocard)Adenosine (Adenocard)
• Mechanism of action− Slows conduction
through the AV node
− Can interrupt reentrant pathways
− The drug of choice for reentry SVT
• Indications− Most forms of stable
narrow-complex SVT
• Contraindications− Bronchoconstrictive or
bronchospastic lung disease
• Adverse reactions− Generally short
duration and mild
• Considerations− Evaluate elderly for
signs of dehydration
Albuterol (Proventil, Ventolin)
Albuterol (Proventil, Ventolin)
• Mechanism of action− Results in smooth-
muscle relaxation in the bronchial tree
• Indications− Treatment of
bronchospasm in patients with COPD/asthma)
• Contraindications− Hypersensitivity
reactions to albuterol
• Adverse reactions− Often dose-related
and include headache, fatigue, lightheadedness, irritability, restlessness
• Considerations− Pregnancy safety:
Category C
− May precipitate angina pectoris and dysrhythmias
Alteplase, Recombinant (Tissue Plasminogen Activator
or rTPA, Activase)
Alteplase, Recombinant (Tissue Plasminogen Activator
or rTPA, Activase)
• Mechanism of action− Restores perfusion
• Indications− Acute myocardial
infarction, STEMI, massive pulmonary emboli, acute ischemic cerebrovascular accident
• Contraindications− Active internal
bleeding− Recent surgery
• Adverse reactions− Intracranial bleeding,
reperfusion dysrhythmias, chest pain, hypotension, GI bleeding, nausea, abdominal pain
• Considerations− Monitor vital signs
closely.
− Observe for bleeding.
Amiodarone (Cordarone, Pacerone)
Amiodarone (Cordarone, Pacerone)
• Mechanism of action− Delays repolarization
and increases the duration of action potential
• Indications− Ventricular fibrillation
• Contraindications− Known
hypersensitivity to amiodarone or iodine
− Cardiogenic shock
• Adverse reactions− Dizziness, fatigue,
malaise
− Congestive heart failure
• Considerations− Pregnancy safety:
Category D
− Monitor patient for hypotension.
Amyl NitriteAmyl Nitrite
• Mechanism of action− Converts hemoglobin
to methemoglobin to prevent toxic effects
• Indications− Cyanide poisoning
• Contraindications− None in emergency
settings
• Adverse reactions− Headache, dizziness,
weakness
• Considerations− Pregnancy safety:
Category X
− Highly flammable
Aspirin (ASA, Bayer, Ecotrin, St. Joseph, and Others)
Aspirin (ASA, Bayer, Ecotrin, St. Joseph, and Others)
• Mechanism of action− Prevents platelets
from clumping together and forming emboli
• Indications− New onset chest pain
suggestive of acute myocardial infarction
• Contraindications− Relatively
contraindicated in patients with active ulcer disease or asthma
• Adverse reactions− Bronchospasm,
anaphylaxis, wheezing in allergic patients, prolonged bleeding
• Considerations− Pregnancy safety:
Category D
− Not recommended in pediatric population
Atenolol (Tenormin)Atenolol
(Tenormin)
• Mechanism of action− Decreases heart rate,
myocardial contractility, and cardiac output
• Indications− To reduce myocardial
ischemia and damage in acute myocardial infarction patients
• Contraindications− Heart failure,
cardiogenic shock, bradycardia
• Adverse reactions− Dizziness,
bronchospasm, bradycardia
• Considerations− Pregnancy safety:
Category D − Atenolol must be
given slowly IV over 5 minutes
− Should be used with caution in patients with liver or renal dysfunction and COPD
Atropine SulfateAtropine Sulfate
• Mechanism of action− Increases heart rate in
life-threatening bradydysrhythmias
• Indications− Hemodynamically
unstable bradycardia
• Contraindications− Tachycardia,
hypersensitivity
• Adverse reactions− Drowsiness,
confusion, headache, tachycardia, palpitations
• Considerations− Pregnancy safety:
Category C
− Moderate doses may cause pupillary dilation.
Benzocaine Spray (Hurricane)Benzocaine Spray (Hurricane)
• Mechanism of action− Stabilizes neuronal
membrane, which blocks the initiation and conduction of nerve impulses
• Indications− Suppresses
pharyngeal and tracheal gag reflex
• Contraindications− People with known
hypersensitivity to benzocaine
• Adverse reactions− Methemoglobinemia
has been reported on extremely rare occasions.
• Considerations− Pregnancy safety:
Category C
− Topical use only; not for ocular use or injection
Bumetanide (Bumex)
Bumetanide (Bumex)
• Mechanism of action− Inhibits the
reabsorption of sodium and chloride in the ascending limb of the loop of Henle
• Indications− Pulmonary edema,
congestive heart failure
• Contraindications− Hypersensitivity to
bumetanide or sulfonamides
• Adverse reactions− Dizziness, headache,
orthostatic hypotension
• Considerations− Pregnancy safety:
Category C
Calcium ChlorideCalcium Chloride
• Mechanism of action− Increases cardiac
contractile state
• Indications− Hypocalcemia,
hyperkalemia, hypermagnesemia
• Contraindications− Hypercalcemia,
ventricular fibrillation, digitalis toxicity
• Adverse reactions− Syncope, cardiac
arrest, dysrhythmia, bradycardia
• Considerations− Pregnancy safety:
Category C
− Do not use routinely in cardiac arrest.
Calcium GluconateCalcium Gluconate
• Mechanism of action− Counteracts the
toxicity of hyperkalemia
• Indications− Hyperkalemia,
hypocalcemia
• Contraindications− Ventricular fibrillation,
digitalis toxicity, hypercalcemia
• Adverse reactions− Syncope, cardiac
arrest, dysrhythmia, bradycardia
• Considerations− Pregnancy safety:
Category C
− Do not administer by IM or SQ
Clopidogrel (Plavix)
Clopidogrel (Plavix)
• Mechanism of action− Inhibits platelet
aggregation
• Indications− Acute coronary
syndrome
− Substitute for aspirin in patients unable to take aspirin
• Contraindications− Active GI bleeding,
intracranial hemorrhage
• Adverse reactions− Severe neutropenia
− Hemorrhaging
• Considerations− Pregnancy safety:
Category B
− Often given with other anticoagulants
Dexamethasone Sodium Phosphate (Decadron)
Dexamethasone Sodium Phosphate (Decadron)
• Mechanism of action− Suppresses acute and
chronic inflammation
• Indications− Anaphylaxis, asthma,
spinal cord injury
• Contraindications− Hypersensitivity, use
caution in suspected systemic sepsis
• Adverse reactions− Headache,
restlessness, euphoria, psychoses
• Considerations− Pregnancy safety:
Category C
− Protect medication from heat. Toxicity and side effects occur with long-term use.
DextroseDextrose
• Mechanism of action− Rapidly increases
serum glucose levels
• Indications− Hypoglycemia, altered
level of consciousness
• Contraindications− Intracranial
hemorrhage
• Adverse reactions− Cerebral hemorrhage
− Cerebral ischemia
− Pulmonary edema
• Considerations− Pregnancy safety:
Category C
Diazepam (Valium and Others)
Diazepam (Valium and Others)
• Mechanism of action− Raises the seizure
threshold; induces amnesia and sedation
• Indications− Acute anxiety states
and agitation, acute alcohol withdrawal
• Contraindications− Hypersensitivity,
narrow-angle glaucoma
• Adverse reactions− Dizziness,
drowsiness, confusion, headache
• Considerations− Pregnancy safety:
Category D
− Short duration for anticonvulsant effect
− Reduce dose by 50% in elderly patients.
Digoxin (Lanoxin)Digoxin (Lanoxin)
• Mechanism of action− Increases force of
myocardial contraction
• Indications− Congestive heart
failure, reentry SVTs, ventricular rate control in atrial flutter and atrial fibrillation
• Contraindications− Ventricular fibrillation,
ventricular tachycardia, digitalis toxicity
• Adverse reactions− Fatigue, headache,
blurred yellow or green vision, seizures
• Considerations− Pregnancy safety:
Category C
− Patient receiving IV digoxin must be on a monitor
Diltiazem (Cardizem)Diltiazem (Cardizem)
• Mechanism of action− Reduces myocardial
oxygen demand
• Indications− Controls rapid
ventricular rates
• Contraindications− Hypotension
− Sick sinus syndrome
• Adverse reactions− Dizziness, weakness,
headache, dyspnea
• Considerations− Pregnancy safety:
Category C
− Use with caution in patients with renal or hepatic dysfunction.
Diphenhydramine (Benadryl)
Diphenhydramine (Benadryl)
• Mechanism of action− Blocks cellular
histamine receptors
• Indications− Symptomatic relief
of allergies, allergic reactions, and anaphylaxis
• Contraindications− Asthma, glaucoma,
pregnancy, hypertension
• Adverse reactions− Drowsiness, sedation,
seizures
• Considerations− Pregnancy safety:
Category B
− Not used in infants
Dobutamine Hydrochloride (Dobutrex)
Dobutamine Hydrochloride (Dobutrex)
• Mechanism of action− Increased myocardial
contractility, stroke volume, and increased cardiac output
• Indications− Cardiogenic shock,
CHF
• Contraindications− Tachydysrhythmias,
severe hypotension
• Adverse reactions− Headache, dyspnea,
tachycardia, hypertension, chest pain
• Considerations− Pregnancy safety:
Category B
− Monitor blood pressure closely.
Dolasetron (Anzemet)
Dolasetron (Anzemet)
• Mechanism of action− Selectively blocks the
action of serotonin
• Indications− Prevention and control
of nausea or vomiting
• Contraindications− Use caution in
patients with cardiac dysrhythmias or electrolyte abnormalities
• Adverse reactions− ECG changes,
dysrhythmias, anaphylactic reaction, headache, hypotension
• Considerations− Pregnancy safety:
Category B − Injectable form should
not be used in patients with chemotherapy-induced nausea and vomiting.
Dopamine Hydrochloride (Intropin)
Dopamine Hydrochloride (Intropin)
• Mechanism of action− Increases myocardial
contractility and stroke volume
• Indications− Cardiogenic and
septic shock, hypotension with low cardiac output states
• Contraindications− Hypovolemic shock,
pheochromocytoma, tachydysrhythmias
• Adverse reactions− Headache, anxiety,
dyspnea, dysrhythmias
• Considerations− Pregnancy safety:
Category C
− Effects are dose-dependent
Epinephrine (Adrenalin)
Epinephrine (Adrenalin)
• Mechanism of action− Blocks histamine
receptors
• Indications− Cardiac arrest,
symptomatic bradycardia
• Contraindications− Hypertension,
hypothermia, pulmonary edema
• Adverse reactions− Nervousness,
restlessness, headache, tremor
• Considerations− Pregnancy safety:
Category C
− May cause syncope in asthmatic children
Epinephrine Racemic (Micronefrin)
Epinephrine Racemic (Micronefrin)
• Mechanism of action− Reduces airway
resistance
• Indications− Bronchial asthma,
prevention of bronchospasm, croup
• Contraindications− Hypertension,
underlying cardiovascular disease, epiglottitis
• Adverse reactions− Headache, anxiety,
fear, nervousness, respiratory weakness
• Considerations− May cause
tachycardia and other dysrhythmias
− Monitor vital signs.
Eptifibatide (Integrilin)
Eptifibatide (Integrilin)
• Mechanism of action− Prevents the
aggregation of platelets
• Indications− Unstable angina and
NSTEMI (ACS) being managed medically
• Contraindications− Any prior intracranial
hemorrhage, known malignant intracranial neoplasm, suspected aortic dissection
• Adverse reactions− Cerebral hemorrhage,
pulmonary hemorrhage, hypotension, GI bleeding
• Considerations− Pregnancy safety:
Category B
− Must be administered only with an infusion pump direct from bottle with a vented IV set
Etomidate (Amidate)Etomidate (Amidate)
• Mechanism of action− Short-acting hypnotic
• Indications− Premedication for
tracheal intubation or cardioversion
• Contraindications− Hypersensitivity,
labor/delivery
• Adverse reactions− Apnea of short
duration, respiratory depression, hypoventilation, hyperventilation
• Considerations− Pregnancy safety:
Category C
− Carefully monitor vital signs.
Fentanyl Citrate (Sublimaze)
Fentanyl Citrate (Sublimaze)
• Mechanism of action− Produces analgesia
and euphoria
• Indications− Pain management,
anesthesia adjunct
• Contraindications− Known
hypersensitivity. Use with caution in traumatic brain injury.
• Adverse reactions− Confusion,
paradoxical excitation, delirium, drowsiness
• Considerations− Pregnancy safety:
Category C
− Chest wall rigidity possible with a high-dose rapid infusion
Flumazenil (Romazicon)Flumazenil (Romazicon)
• Mechanism of action− Reverses the sedative
effects of benzodiazepines
• Indications− Reversal of respiratory
depression and sedative effects from benzodiazepine
• Contraindications− Hypersensitivity,
tricyclic antidepressant overdose, seizure-prone patients
• Adverse reactions− Seizures, dizziness,
agitation, confusion, headache, visual disturbances
• Considerations− Pregnancy safety:
Category C
− Not recommended in combined drug overdoses
Fosphenytoin (Cerebyx)
Fosphenytoin (Cerebyx)
• Mechanism of action− Elevates the
excitability threshold of the cell, reducing its response to stimuli
• Indications− Status epilepticus,
seizure disorder
• Contraindications− Bradycardia, Adams-
Stokes syndrome, second- or third-degree AV blocks
• Adverse reactions− Severe hypotension,
bradycardia, dysrhythmias
• Considerations− Pregnancy safety:
Category D
− Use with caution in patients with hepatic and renal impairment and diabetic, elderly, and debilitated patients.
Furosemide (Lasix)
Furosemide (Lasix)
• Mechanism of action− Causes increased
urine output
• Indications− CHF, pulmonary
edema, hypertensive crisis
• Contraindications− Hypovolemia, anuria,
hypotension
• Adverse reactions− Dizziness, headache,
ECG changes, weakness
• Considerations− Pregnancy safety:
Category C
− Ototoxicity, deafness, and projectile vomiting can occur with rapid administration.
Glucagon (GlucaGen)Glucagon (GlucaGen)
• Mechanism of action− Increases blood
glucose level
• Indications− Altered level of
consciousness when hypoglycemia is suspected
• Contraindications− Hyperglycemia,
hypersensitivity
• Adverse reactions− Dizziness, headache,
hypertension, tachycardia
• Considerations− Pregnancy safety:
Category B
− Should be used in conjunction with 50% dextrose whenever possible
Haloperidol Lactate (Haldol)
Haloperidol Lactate (Haldol)
• Mechanism of action− Inhibits central
nervous system catecholamine receptors
• Indications− Acute psychotic
episodes
• Contraindications− Parkinson's disease,
depressed mental status
• Adverse reactions− Seizures, sedation,
confusion, restlessness
• Considerations− Pregnancy safety:
Category C
− Treat hypotension secondary to haloperidol with fluids and norepinephrine, not epinephrine
Heparin SodiumHeparin Sodium
• Mechanism of action− Affects clotting factors
IX, XI, XII, plasmin; does not lyse existing clots
• Indications− Acute myocardial
infarction, prophylaxis and treatment of thromboembolic disorders
• Contraindications− Hypersensitivity,
active bleeding
• Adverse reactions− Pain, anaphylaxis,
shock, hematuria
• Considerations− Pregnancy safety:
Category C
− Heparin does not lyse existing clots.
Hydrocortisone Sodium Succinate (Solu-Cortef)Hydrocortisone Sodium Succinate (Solu-Cortef)
• Mechanism of action− Anti-inflammatory;
immunosuppressive with salt-retaining actions
• Indications− Shock due to acute
adrenocortical insufficiency, anaphylaxis, asthma, and COPD
• Contraindications− Systemic fungal
infections, premature infants
• Adverse reactions− Headache, vertigo,
pulmonary tuberculosis
• Considerations− Pregnancy safety:
Category C
− May be used in status asthmaticus as a second-line drug
Hydroxocobalamin (Cyanokit)Hydroxocobalamin (Cyanokit)
• Mechanism of action− Binds with cyanide to
prevent its toxic effects
• Indications− Treatment of known or
suspected cyanide poisoning
• Contraindications− None in the
emergency setting
• Adverse reactions− Hypertension, allergic
reactions, GI bleeding, nausea, vomiting
• Considerations− Pregnancy safety:
Category C
− Make sure to reassess the patient’s airway, oxygenation, and hydration during administration.
Hydroxyzine (Atarax, Vistaril)
Hydroxyzine (Atarax, Vistaril)
• Mechanism of action− Potentiates effects of
analgesics
• Indications− Controls nausea and
vomiting in anxiety reactions and motion sickness
• Contraindications− Hypersensitivity, early
pregnancy
• Adverse reactions− Drowsiness, agitation,
ataxia, dizziness, headache, weakness
• Considerations− Pregnancy safety:
Category C
− Should be administered by IM injection only
InsulinInsulin
• Mechanism of action− Allows glucose
transport into cells of all tissues
• Indications− Not used in
emergency prehospital setting
• Contraindications− Hypoglycemia,
hypokalemia
• Adverse reactions− Weakness, fatigue,
confusion, headache
• Considerations− Pregnancy safety:
Category B
− Insulin is the drug of choice for control of diabetes in pregnancy.
Ipratropium (Atrovent)
Ipratropium (Atrovent)
• Mechanism of action− Inhibits interaction
of acetylcholine at receptor sites of bronchial smooth muscle
• Indications− Persistent
bronchospasm, COPD exacerbation
• Contraindications− Hypersensitivity to
ipratropium, atropine, alkaloids, peanuts
• Adverse reactions− Headache, dizziness,
nervousness, fatigue
• Considerations− Pregnancy safety:
Category B
− Shake well before use.
Isoetharine (Bronchosol, Bronkometer)
Isoetharine (Bronchosol, Bronkometer)
• Mechanism of action− Relaxes smooth
muscle of bronchioles
• Indications− Acute bronchial
asthma, bronchospasm
• Contraindications− Use with caution in
patients with diabetes, hyperthyroidism, and cardiovascular and cerebrovascular disease.
• Adverse reactions− Nervousness, dose-
related tachycardia, palpitations
• Considerations− None
Ketorolac Tromethamine (Toradol)
Ketorolac Tromethamine (Toradol)
• Mechanism of action− Potent analgesic
• Indications− Short-term
management of moderate to severe pain
• Contraindications− Allergy to salicylates
or other nonsteroidal anti-inflammatory drugs
• Adverse reactions− Drowsiness,
dizziness, headache, sedation
• Considerations− Pregnancy safety:
Category C
− Use with caution in elderly patients due to higher risk of renal and fatal GI adverse reactions.
Labetalol (Normodyne, Trandate)
Labetalol (Normodyne, Trandate)
• Mechanism of action− Blood pressure
reduction without reflex tachycardia
• Indications− Moderate to severe
hypertension
• Contraindications− Bronchial asthma,
congestive heart failure, cardiogenic shock
• Adverse reactions− Fatigue, weakness,
depression, headache, dizziness
• Considerations− Pregnancy safety:
Category C
− Blood pressure, pulse rate, and ECG should be monitored continuously.
Levalbuterol (Xopenex)
Levalbuterol (Xopenex)
• Mechanism of action− Relaxation of
bronchial tree and peripheral vasculature
• Indications− Treatment of acute
bronchospasm in patients with reversible obstructive airway disease
• Contraindications− Hypersensitivity
to drug and other sympathomimetics
• Adverse reactions− Headache, anxiety,
dizziness, restlessness, hallucinations
• Considerations− Pregnancy safety:
Category C
− Use with caution in patients with cardiac dysrhythmias and cardiovascular disorders.
Lidocaine Hydrochloride (Xylocaine)
Lidocaine Hydrochloride (Xylocaine)
• Mechanism of action− Decreases
automaticity
• Indications− Alternative to
amiodarone in cardiac arrest from ventricular tachycardia
• Contraindications− Hypersensitivity,
second- or third-degree AV block in the absence of an artificial pacemaker
• Adverse reactions− Anxiety, drowsiness,
confusion, seizures
• Considerations− Apnea induced with
succinylcholine may be prolonged with high doses of lidocaine.
− Exceedingly high doses can result in coma or death.
Lorazepam (Ativan)
Lorazepam (Ativan)
• Mechanism of action− Anxiolytic,
anticonvulsant, and sedative effect
• Indications− Initial control of status
epilepticus or severe recurrent seizures
• Contraindications− Acute narrow-angle
glaucoma, coma, shock
• Adverse reactions− Dizziness,
drowsiness, CNS depression, headache
• Considerations− Pregnancy safety:
Category D
− Monitor respiratory rate and blood pressure during administration.
Magnesium SulfateMagnesium Sulfate
• Mechanism of action− Reduces striated
muscle contractions
• Indications− Seizures of
eclampsia, torsades de pointes, hypomagnesemia
• Contraindications− Heart block,
myocardial damage
• Adverse reactions− Drowsiness, CNS
depression, respiratory depression
• Considerations− Pregnancy safety:
Category A
− Recommended that the drug not be administered in the 2 hours before delivery, if possible
Mannitol (Osmitrol)Mannitol (Osmitrol)
• Mechanism of action− Decreases cerebral
edema and intracranial pressure
• Indications− Cerebral edema
• Contraindications− Hypotension,
pulmonary edema, severe dehydration, intracranial bleeding, CHF
• Adverse reactions− Headache, confusion,
seizures, pulmonary edema
• Considerations− Pregnancy safety:
Category C
− May crystallize at low temperatures; store at room temperature
− Have ventilatory support available.
Meperidine Hydrochloride (Demerol)
Meperidine Hydrochloride (Demerol)
• Mechanism of action− Primarily acts as an
analgesic and a sedative
• Indications− Analgesia for
moderate to severe pain
• Contraindications− Hypersensitivity to
narcotics
• Adverse reactions− Seizures, confusion,
sedation, dysphoria, headache
• Considerations− Pregnancy safety:
Category C
− Use with caution in patients with asthma and COPD
Metaproterenol Sulfate (Alupent)
Metaproterenol Sulfate (Alupent)
• Mechanism of action− Acts directly on
bronchial smooth muscle causing relaxation
• Indications− Bronchial asthma,
COPD
• Contraindications− Tachydysrhythmia,
hypersensitivity, tachycardia caused by digitalis toxicity
• Adverse reactions− Nervousness, tremor,
headache, anxiety
• Considerations− Pregnancy safety:
Category C
− Monitor for hypotension and tachycardia.
Methylprednisolone Sodium Succinate (Solu-Medrol)
Methylprednisolone Sodium Succinate (Solu-Medrol)
• Mechanism of action− Suppresses acute and
chronic inflammation
• Indications− Acute spinal cord
trauma, anaphylaxis, bronchodilator for unresponsive asthma
• Contraindications− Premature infants,
systemic fungal infections
• Adverse reactions− Depression, euphoria,
headache, restlessness, seizure
• Considerations− Pregnancy safety:
Category C
− Not effective if time of spinal cord injury greater than 8 hours
Metoprolol Tartrate (Lopressor)Metoprolol Tartrate (Lopressor)
• Mechanism of action− Decreases heart rate
• Indications− PSVT, atrial flutter,
atrial fibrillation
• Contraindications− Heart failure, second-
or third-degree AV block
• Adverse reactions− Weakness, dizziness,
depression, bronchospasm
• Considerations− Pregnancy safety:
Category C
− Metoprolol must be given slow IV over 5 minutes
Midazolam Hydrochloride (Versed)
Midazolam Hydrochloride (Versed)
• Mechanism of action− Causes sedative,
anxiolytic, amnesic, and hypnotic effects
• Indications− Sedation for medical
procedures
• Contraindications− Acute narrow-angle
glaucoma, shock, coma, alcohol intoxication
• Adverse reactions− Headache,
somnolence, respiratory depression
• Considerations− Pregnancy safety:
Category D
− Administer immediately prior to intubation procedure.
Morphine Sulfate (Roxanol, MS Contin)
Morphine Sulfate (Roxanol, MS Contin)
• Mechanism of action− Alleviates pain
through CNS action
• Indications− Severe CHF, acute
cardiogenic pulmonary edema
• Contraindications− Head injury,
exacerbated COPD, depressed respiratory drive
• Adverse reactions− Confusion, sedation,
headache, CNS depression
• Considerations− Pregnancy safety:
Category C
− Morphine rapidly crosses the placenta.
Nalbuphine Hydrochloride (Nubain)
Nalbuphine Hydrochloride (Nubain)
• Mechanism of action− Activates opiate
receptor
• Indications− Chest pain with acute
MI, acute pain
• Contraindications− Head injury,
undiagnosed abdominal pain, diarrhea from poison, hypovolemia, hypotension
• Adverse reactions− Headache, dizziness,
vertigo, seizure
• Considerations− Pregnancy safety:
Category B
− Use with caution in patients with impaired respiratory function.
Naloxone Hydrochloride (Narcan)
Naloxone Hydrochloride (Narcan)
• Mechanism of action− Reverses respiratory
depression secondary to opiate drugs
• Indications− Opiate overdose,
complete or partial reversal of central nervous system and respiratory depression induced by opioids
• Contraindications− Use with caution in
narcotic-dependent patients
• Adverse reactions− Restlessness,
seizures, dyspnea, pulmonary
• Considerations− Pregnancy safety:
Category C
Nifedipine (Procardia, Adalat)
Nifedipine (Procardia, Adalat)
• Mechanism of action− Inhibits movement
of calcium ions across cell membranes
• Indications− Hypertensive crisis,
angina pectoris
• Contraindications− Compensatory
hypertension, hypotension
• Adverse reactions− Headache, dizziness,
nervousness, weakness, mood changes
• Considerations− Pregnancy safety:
Category C
− Have beta blocker available for control of reflex tachycardia
Nitroglycerin (Nitrostat, Nitro-Bid, Tridil)
Nitroglycerin (Nitrostat, Nitro-Bid, Tridil)
• Mechanism of action− Smooth muscle
relaxant acting on vasculature, bronchial, uterine, intestinal smooth muscle
• Indications− Acute angina pectoris,
ischemic chest pain
• Contraindications− Hypotension,
hypovolemia, intracranial bleeding or head injury
• Adverse reactions− Headache, dizziness,
weakness, reflex tachycardia
• Considerations− Pregnancy safety:
Category C
− Hypotension more common in the elderly
Nitropaste (Nitro-Bid Ointment)
Nitropaste (Nitro-Bid Ointment)
• Mechanism of action− Smooth muscle
relaxant
• Indications− Acute angina pectoris
• Contraindications− Hypotension,
hypovolemia, intracranial bleeding or head injury
• Adverse reactions− Headache, dizziness,
weakness
• Considerations− Pregnancy safety:
Category C
− Not a great value in prehospital arena
Nitrous Oxide 50:50 (Nitronox)Nitrous Oxide 50:50 (Nitronox)
• Mechanism of action− Exact mechanism
unknown
• Indications− Moderate to severe
pain, anxiety, apprehension
• Contraindications− Impaired level of
consciousness, head injury
• Adverse reactions− Lightheadedness,
drowsiness, respiratory depression
• Considerations− Pregnancy safety:
Category C
− Nitrous oxide increases the incidence of spontaneous abortion.
Norepinephrine Bitartrate (Levophed)
Norepinephrine Bitartrate (Levophed)
• Mechanism of action− Potent alpha-agonist
resulting in intense peripheral vasoconstriction
• Indications− Cardiogenic shock,
unresponsive to fluid resuscitation
• Contraindications− Hypotensive patients
with hypovolemia
• Adverse reactions− Headache, anxiety,
dizziness
• Considerations− Pregnancy safety:
Category C.
− May cause fetal anoxia when used in pregnancy
Ondansetron Hydrochloride (Zofran)
Ondansetron Hydrochloride (Zofran)
• Mechanism of action− Blocks action of
serotonin
• Indications− Prevention and control
of nausea or vomiting
• Contraindications− Known allergy to
ondansetron
• Adverse reactions− Headache, malaise,
wheezing
• Considerations− Pregnancy safety:
Category B
Oral Glucose (Insta-Glucose)Oral Glucose
(Insta-Glucose)
• Mechanism of action− Provides an increase
in circulating blood glucose levels
• Indications− Conscious patients
with suspected hypoglycemia
• Contraindications− Decreased level of
consciousness, nausea, vomiting
• Adverse reactions− Nausea, vomiting
• Considerations− Must be swallowed.
Glucose is not absorbed sublingually or buccally.
OxygenOxygen
• Mechanism of action− Reverses hypoxemia
• Indications− Confirmed or
expected hypoxemia, ischemic chest pain
• Contraindications− Certain patients with
COPD will not tolerate oxygen concentrations over 35%.
• Adverse reactions− Decreased level of
consciousness (COPD patients), decreased respiratory drive in COPD patients
• Considerations− Be familiar with liter
flow and each type of delivery device used.
Oxytocin (Pitocin)
Oxytocin (Pitocin)
• Mechanism of action− Increases uterine
contractions
• Indications− Postpartum
hemorrhage after infant and placental delivery
• Contraindications− Presence of second
fetus, unfavorable fetal position
• Adverse reactions− Coma, seizures,
anxiety
• Considerations− Pregnancy safety:
Category C
− Monitor vital signs including fetal heart rate and uterine tone closely.
Pancuronium Bromide (Pavulon)
Pancuronium Bromide (Pavulon)
• Mechanism of action− Binds to the receptor
for acetylcholine at the neuromuscular junction
• Indications− Induction or
maintenance of paralysis after intubation to assist ventilations
• Contraindications− Hypersensitivity,
inability to control airway and/or support ventilations with oxygen and positive pressure
• Adverse reactions− Weakness, prolonged
neuromuscular block, bronchospasm
• Considerations− Always sedate the
patient before administering.
Phenobarbital (Luminal)
Phenobarbital (Luminal)
• Mechanism of action− Generally unknown
but believed to reduce neuronal excitability
• Indications− Prevention and
treatment of seizure activity, status epilepticus
• Contraindications− Patients with
porphyria, history of sedative or hypnotic addiction
• Adverse reactions− Coma, drowsiness,
headache, vertigo, paradoxic excitation
• Considerations− Pregnancy safety:
Category D
− Potential for abuse
− Carefully monitor vital signs.
Phenytoin (Dilantin)
Phenytoin (Dilantin)
• Mechanism of action− Promotes sodium
efflux from neurons
• Indications− Prophylaxis and
treatment of major motor seizures
• Contraindications− Hypersensitivity,
bradycardia
• Adverse reactions− Ataxia, agitation,
dizziness, headache, drowsiness
• Considerations− Pregnancy safety:
Category D
− Carefully monitor vital signs.
Pralidoxime (2-PAM, Protopam)
Pralidoxime (2-PAM, Protopam)
• Mechanism of action− Acts as an antidote to
organophosphate and pesticide poisonings
• Indications− As an antidote in the
treatment of poisoning
• Contraindications− Reduce dose in
patients with impaired renal function, and patients with myasthenia gravis
• Adverse reactions− Dizziness,
drowsiness, headache, neuromuscular blockade
• Considerations− Pregnancy safety:
Category C
− Slow IV infusion prevents tachycardia, laryngospasm, muscle rigidity
Procainamide Hydrochloride (Pronestyl)
Procainamide Hydrochloride (Pronestyl)
• Mechanism of action− Suppresses
intraventricular conduction
• Indications− Stable monomorphic
ventricular tachycardia with normal QT interval
• Contraindications− Torsades de pointes,
second- and third- degree heart atrioventricular block
• Adverse reactions− Confusion, seizures,
hypotension, bradycardia
• Considerations− Pregnancy safety:
Category C
− Potent vasodilation and negative inotropic effects
Promethazine Hydrochloride (Phenergan)
Promethazine Hydrochloride (Phenergan)
• Mechanism of action− H-1 receptor
antagonist; blocks action of histamine
• Indications− Nausea/vomiting,
motion sickness, sedation for patients in labor
• Contraindications− Coma, central
nervous system depression from alcohol, barbiturates, or narcotics
• Adverse reactions− Headache, dizziness,
drowsiness, confusion, restlessness, wheezing
• Considerations− Pregnancy safety:
Category C
− Convulsions and sudden death when used with children
Propofol (Diprivan)Propofol (Diprivan)
• Mechanism of action− Produces rapid
and brief state of general anesthesia
• Indications− Anesthesia induction/
maintenance, sedation for mechanically ventilated patients
• Contraindications− Hypovolemia, known
sensitivity
• Adverse reactions− Seizure, apnea,
dysrhythmias, asystole, hypotension, hypertension
• Considerations− Pregnancy safety:
Category B
− Avoid rapid administration in elderly patients to avoid hypotension and airway obstruction.
Propranolol Hydrochloride (Inderal)
Propranolol Hydrochloride (Inderal)
• Mechanism of action− Reduces chronotropic,
inotropic, and vasodilator response to beta-adrenergic stimulation
• Indications− Hypertension, angina
pectoris
• Contraindications− Sinus bradycardia,
second- or third-degree AV block
• Adverse reactions− Weakness,
depression, fatigue, anxiety, dizziness, bronchospasm
• Considerations− Pregnancy safety:
Category C − Closely monitor
patient during administration.
− Use with caution in elderly patients.
− Atropine should be readily available.
Rocuronium Bromide (Zemuron)
Rocuronium Bromide (Zemuron)
• Mechanism of action− Produces skeletal
muscle paralysis
• Indications− Rapid sequence
intubation
• Contraindications− Known sensitivity to
bromides. Use with caution in heart and liver disease.
• Adverse reactions− Bronchospasm,
wheezing, rhonchi, respiratory depression, apnea
• Considerations− Pregnancy safety:
Category B
− Decrease doses for patients with renal disease.
− Sedate patient before administering.
Sodium BicarbonateSodium Bicarbonate
• Mechanism of action− Buffers metabolic
acidosis and lactic acid buildup
• Indications− Metabolic acidosis
during cardiac arrest, tricyclic antidepressant, aspirin
• Contraindications− Metabolic/respiratory
alkalosis, hypokalemia, electrolyte imbalance
• Adverse reactions− Hypernatremia,
metabolic alkalosis, tissue sloughing, cellulitis
• Considerations− Pregnancy safety:
Category C
− Repeat as needed in tricyclic antidepressant overdose until QRS narrows
Sodium NitrateSodium Nitrate
• Mechanism of action− Reacts with
hemoglobin to form methemoglobin, which reacts with cyanide
• Indications− Cyanide poisoning
• Contraindications− None in the
emergency setting
• Adverse reactions− Hypotension,
tachycardia, fainting, nausea, vomiting
• Considerations− Pregnancy safety:
Category C
− Potent vasodilator causes significant hypotension if given too rapidly
Sodium ThiosulfateSodium Thiosulfate
• Mechanism of action− Converts cyanide to
the less toxic thiocyanate, which is then excreted in the urine
• Indications− Cyanide poisoning
• Contraindications− None in the
emergency setting
• Adverse reactions− Diarrhea
• Considerations− Pregnancy safety:
Category C
− If response to treatment is inadequate, repeat sodium nitrite and sodium thiosulfate
Streptokinase (Streptase)
Streptokinase (Streptase)
• Mechanism of action− Combines with
plasminogen to convert free plasminogen to the proteolytic enzyme, plasmin
• Indications− Acute myocardial
infarction, massive pulmonary emboli, arterial thrombosis/ embolism, to clear intraventricular cannula
• Contraindications− Hypersensitivity,
active bleeding, recent cerebral vascular accident
• Adverse reactions− Intracranial
hemorrhage, bronchospastic hemoptysis, ARDS
• Considerations− Pregnancy safety:
Category C
Succinylcholine Chloride (Anectine)
Succinylcholine Chloride (Anectine)
• Mechanism of action− Ultra-short-acting
depolarizing skeletal muscle relaxant
• Indications− Rapid-sequence
intubation
• Contraindications− Acute narrow-angle
glaucoma, penetrating eye injuries, malignant hyperthermia
• Adverse reactions− Apnea, respiratory
depression, bradydysrhythmia, tachydysrhythmia
• Considerations− Pregnancy safety:
Category C
− If the patient is conscious, explain the effects of the drug before administration.
Terbutaline Sulfate (Brethine)Terbutaline Sulfate (Brethine)
• Mechanism of action− Relaxation of
bronchial tree and peripheral vasculature with minimal cardiac effects
• Indications− Bronchial asthma,
bronchospasm associated with exercise
• Contraindications− Hypersensitivity,
tachydysrhythmias
• Adverse reactions− CNS stimulation,
headache, seizure, restlessness, apprehension
• Considerations− Pregnancy safety:
− Category B
− Monitor vital signs.
Thiamine (Betaxin)Thiamine (Betaxin)
• Mechanism of action− Combines with ATP
to form thiamine pyrophosphate coenzyme
• Indications− Coma of unknown
origin, delirium tremens, beriberi, Wernicke encephalopathy
• Contraindications− None
• Adverse reactions− Anxiety, dyspnea,
respiratory failure, vasodilation
• Considerations− Pregnancy safety:
Category A
− Rapid or large IV doses may cause respiratory difficulties, hypotension, and vasodilation.
Tirofiban Hydrochloride (Aggrastat)
Tirofiban Hydrochloride (Aggrastat)
• Mechanism of action− Inhibits aggregation of
platelets
• Indications− Acute coronary
syndrome
• Contraindications− Trauma or major
surgery within the past 30 days
• Adverse reactions− Dizziness, pain,
sweating, intracranial bleeding, CVA
• Considerations− Pregnancy safety:
Category B
− Must be administered only with an infusion pump direct from bottle with a vented IV set
− Severe spontaneous bleeding risk
Vasopressin (Pitressin)
Vasopressin (Pitressin)
• Mechanism of action− Stimulation of smooth
muscle receptors
• Indications− Alternative
vasopressor to the first or second dose of epinephrine in cardiac arrest
• Contraindications− Use with caution in
patients with coronary artery disease, epilepsy, or heart failure.
• Adverse reactions− Dizziness, headache,
bronchial constriction, MI, chest pain, angina
• Considerations− Pregnancy safety:
Category C
− May increase peripheral vascular resistance and provoke cardiac ischemia and angina
Vecuronium Bromide (Norcuron)
Vecuronium Bromide (Norcuron)
• Mechanism of action− Neuromuscular agent
that results in neuromuscular blockade
• Indications− Rapid-sequence
intubation
• Contraindications− Acute narrow-angle
glaucoma, penetrating
eye injuries
• Adverse reactions− Weakness, prolonged
neuromuscular block, bronchospasm, apnea
• Considerations− Pregnancy safety:
Category C
− If patient is conscious, explain the effect of the medication before administration and always sedate the patient before using vecuronium.
Verapamil Hydrochloride (Isoptin, Calan)
Verapamil Hydrochloride (Isoptin, Calan)
• Mechanism of action− Prolongs AV nodal
refractory period, dilates coronary arteries and arterioles
• Indications− Paroxysmal
supraventricular tachycardia, atrial flutter, and atrial fibrillation with rapid ventricular response
• Contraindications− Wolff-Parkinson-White
syndrome, Lown-Ganong-Levine syndrome
• Adverse reactions− Dizziness, headache,
pulmonary edema
• Considerations− Pregnancy safety:
Category C
− Closely monitor patient’s vital signs.
IV Solutions (Colloids and Crystalloids)
IV Solutions (Colloids and Crystalloids)
• Colloids− Expand plasma volume
− Most often used in hypovolemic shock states
• Crystalloid solutions are used for:− Electrolyte replacement
− A route for medication
− Short-term intravascular volume expansion
Plasma Protein Fraction (Plasmanate)
Plasma Protein Fraction (Plasmanate)
• Mechanism of action− Increases
intravascular volume
• Indications− Hypovolemic shock,
especially burn shock
• Contraindications− No major
contraindications
• Adverse reactions− Chills, fever, urticaria
(hives), nausea, and vomiting
• Considerations− Do not use if the
solution is cloudy or if you see sedimentation.
DextranDextran
• Mechanism of action− Sugar-containing
colloid used as an intravascular volume expander
• Indications− Hypovolemic shock
• Contraindications− Patients with
congestive heart failure, renal failure, or known bleeding disorders
• Adverse reactions− Rash, itching,
dyspnea, chest tightness, and mild hypotension
• Considerations− In the management of
burn shock, it is especially important to follow standard fluid resuscitation regimens to prevent possible circulatory overload.
Hetastarch (Hespan)
Hetastarch (Hespan)
• Mechanism of action− A starch-containing
colloid used as an intravascular volume expander
• Indications− Hypovolemic shock,
especially burn shock; septic shock
• Contraindications− No major
contraindications
• Adverse reactions− Nausea, vomiting,
mild febrile reactions, chills, itching, and urticaria
• Considerations− Pregnancy safety:
Category C
− Patients allergic to corn may be allergic to hetastarch.
Lactated Ringer’s (Hartmann’s Solution)
Lactated Ringer’s (Hartmann’s Solution)
• Mechanism of action− Replaces water
and electrolytes
• Indications− Hypovolemic shock;
keep open IV
• Contraindications− Should not be used in
patients with congestive heart failure or renal failure
• Adverse reactions− Rare in therapeutic
dosages
• Considerations− None
5% Dextrose in Water (D5W)
5% Dextrose in Water (D5W)
• Mechanism of action− Provides nutrients in
the form of dextrose as well as free water
• Indications− For dilution of
concentrated drugs for intravenous infusion
• Contraindications− Should not be used as
a fluid replacement for hypovolemic states
• Adverse reactions− Rare in therapeutic
dosages
• Considerations− Should not be used
with phenytoin or amrinone
10% Dextrose in Water (D10W)10% Dextrose in Water (D10W)
• Mechanism of action− Provides nutrients in
the form of dextrose as well as free water
• Indications− Neonatal
resuscitation, hypoglycemia
• Contraindications− Should not be used as
a fluid replacement for hypovolemic states
• Adverse reactions− Rare in therapeutic
dosages
• Considerations− None
0.9% Sodium Chloride (Normal Saline)
0.9% Sodium Chloride (Normal Saline)
• Mechanism of action− Replaces water
and electrolytes
• Indications− Heat-related problems
(heat exhaustion, heat stroke), freshwater drowning, hypovolemia
• Contraindications− Should not be used
in patients with congestive heart failure
• Adverse reactions− Rare in therapeutic
dosages
• Considerations− None
0.45% Sodium Chloride (½ Normal Saline)
0.45% Sodium Chloride (½ Normal Saline)
• Mechanism of action− Replaces free water
and electrolytes
• Indications− Patients with
diminished renal or cardiovascular function for which rapid rehydration is not indicated
• Contraindications− Cases in which rapid
rehydration is indicated
• Adverse reactions− Rare in therapeutic
dosages
• Considerations− None
5% Dextrose in 0.45% Sodium Chloride (D5½NS)
5% Dextrose in 0.45% Sodium Chloride (D5½NS)
• Mechanism of action− Replaces free water
and electrolytes and provides nutrients in the form of dextrose
• Indications− Heat exhaustion,
diabetic disorders
• Contraindications− Should not be used
when rapid fluid resuscitation is indicated
• Adverse reactions− Rare in therapeutic
dosages
• Considerations− None
5% Dextrose in 0.9% Sodium Chloride (D5NS)
5% Dextrose in 0.9% Sodium Chloride (D5NS)
• Mechanism of action− Replaces free water
and electrolytes and provides nutrients in the form of dextrose
• Indications− Heat-related
disorders, freshwater drowning
• Contraindications− Should not be given to
patients with impaired cardiac or renal function
• Adverse reactions− Rare in therapeutic
dosages
• Considerations− None
5% Dextrose in Lactated Ringer’s (D5LR)
5% Dextrose in Lactated Ringer’s (D5LR)
• Mechanism of action− Replaces water and
electrolytes and provides nutrients in the form of dextrose
• Indications− Hypovolemic shock,
hemorrhagic shock
• Contraindications− Should not be
administered to patients with decreased renal or cardiovascular function
• Adverse reactions− Rare in therapeutic
dosages
• Considerations− None
SummarySummary
• Paramedics are required to know the names, class, mechanism of action, adverse reactions and side effects, interactions, indications, contraindications, complications, routes of administration, dose, and specific administration considerations for many emergency medications and intravenous fluids.
• Individual states have the authority to include additional medications, which may be taught by your local training agency.
SummarySummary
• Because paramedics must make quick decisions about when to administer medications, what medications to administer, and when administering certain medications would be harmful to the patient, it is critically important they develop a solid understanding of the information in this chapter and stay up to date on the latest pharmacologic information.
CreditsCredits
• Chapter opener: © Jones & Bartlett Learning. Courtesy of MIEMSS.
• Backgrounds: Orange—© Keith Brofsky/Photodisc/Getty Images; Red—© Margo Harrison/ShutterStock, Inc.;Gold—Jones & Bartlett Learning. Courtesy of MIEMSS; Lime—© Photodisc.
• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.