Paramedic Inter Facility Transfer Training MEDICATION CLASSIFICATIONS.

Paramedic Inter Facility Paramedic Inter Facility Transfer Transfer TrainingTraining

MEDICATION MEDICATION CLASSIFICATIONSCLASSIFICATIONS

Medication and TransportMedication and Transport

• Most PIFT medications are not found in Most PIFT medications are not found in the National Standard Curriculum for the National Standard Curriculum for ParamedicParamedic

• Medications usually found being Medications usually found being administered to critical care patientsadministered to critical care patients

CLASSIFICATIONS OF CLASSIFICATIONS OF MEDICATIONSMEDICATIONS

18 classifications of 18 classifications of drugs plus OTC drugs plus OTC

medicationsmedications

CLASSIFICATIONS OF CLASSIFICATIONS OF MEDICATIONSMEDICATIONS

• AnticoagulantsAnticoagulants

• AnticonvulsantsAnticonvulsants• Antidiabetics Antidiabetics • Antidysrhythmics Antidysrhythmics • Antihypertensives Antihypertensives • Anti-infectivesAnti-infectives• AntipsychoticsAntipsychotics• Cardiac glycosides Cardiac glycosides • CorticosteroidsCorticosteroids• DrotrecoginDrotrecogin

• GI AgentsGI Agents• IV fluidsIV fluids• NarcoticsNarcotics• Parenteral NutritionParenteral Nutrition• Platelet Aggregation InhibitorsPlatelet Aggregation Inhibitors• Respiratory MedicationsRespiratory Medications• Sedatives Sedatives • Vasoactive AgentsVasoactive Agents

ALLERGIC REACTIONSALLERGIC REACTIONS

• All medications have the All medications have the potential to create an potential to create an allergic reactionallergic reaction

• Be vigilant for signs of Be vigilant for signs of allergic reactions or allergic reactions or anaphylaxisanaphylaxis

• Treat according to Treat according to MEMS protocolMEMS protocol

• OK, let’s look at the drug OK, let’s look at the drug classifications in the PIFT programclassifications in the PIFT program

ANTICOAGULANTSANTICOAGULANTS

• Used to prevent extension of existing Used to prevent extension of existing clot or formation of new blood clotsclot or formation of new blood clots

• Does not dissolve existing clotsDoes not dissolve existing clots

• Patients may be on these drugs for Patients may be on these drugs for extended periods of timeextended periods of time

• PATIENTS ON ANTICOAGULANTSPATIENTS ON ANTICOAGULANTS

• MI or suspected MI patientsMI or suspected MI patients

• DVT—deep vein thrombosisDVT—deep vein thrombosis

• pulmonary embolismpulmonary embolism

• DIC—disseminated intravascular DIC—disseminated intravascular coagulationcoagulation

• Other clotting-related disordersOther clotting-related disorders


• Most commonly used anticoagulants:Most commonly used anticoagulants:

• HeparinHeparin

• Lovenox (Enoxaparin)Lovenox (Enoxaparin)


Generally administered IV but in certain Generally administered IV but in certain cases may be given SQcases may be given SQ

• What to watch for:What to watch for:

• Signs of bleeding, either internally or Signs of bleeding, either internally or externallyexternally

• Monitor vitals frequentlyMonitor vitals frequently

• Signs and symptoms of shockSigns and symptoms of shock

• Altered level of consciousnessAltered level of consciousness


• Potential interventions in case of Potential interventions in case of adverse reaction:adverse reaction:

• Consider discontinuing drugConsider discontinuing drug

• Control any external bleedingControl any external bleeding

• Treat for shockTreat for shock

• Consider contacting medical controlConsider contacting medical control


THROMBOLYTICSTHROMBOLYTICS

• Paramedics are not permitted to Paramedics are not permitted to transport patients with thrombolytic transport patients with thrombolytic drugs running drugs running

• BUT…..BUT…..– Paramedics may transport patients shortly Paramedics may transport patients shortly

after completion of thrombolytic therapy.after completion of thrombolytic therapy.– These patients may present in several These patients may present in several

different ways…different ways…

• Patients may have received Patients may have received thrombolytics for either an acute MI or thrombolytics for either an acute MI or non-hemorrhagic CVAnon-hemorrhagic CVA

• Patients have reperfused and have Patients have reperfused and have improved OR…improved OR…

• Failed perfusion and continue to show Failed perfusion and continue to show symptomssymptoms


• What to watch for during transport:What to watch for during transport:– Signs of bleedingSigns of bleeding

• Particularly intracranial or GI bleedingParticularly intracranial or GI bleeding

– Signs of shock Signs of shock

– Altered level of consciousnessAltered level of consciousness

– HypotensionHypotension

– DysrhythmiasDysrhythmias


• Potential interventions for adverse Potential interventions for adverse reactions:reactions:– Treat dysrhythmias as per Maine EMS Treat dysrhythmias as per Maine EMS

protocolsprotocols

– General supportive measuresGeneral supportive measures

– Consider fluids for hypotensionConsider fluids for hypotension

– Contact OLMC for options including Contact OLMC for options including diversiondiversion


ANTICONVULSANTSANTICONVULSANTS

• Used primarily to prevent or treat Used primarily to prevent or treat seizuresseizures

• Seizures are often associated with Seizures are often associated with epilepsy, head injury, fever, infection or epilepsy, head injury, fever, infection or unknown etiologyunknown etiology


• Anticonvulsants consist of Anticonvulsants consist of three types of drugs:three types of drugs:

1.1.BenzodiazepinesBenzodiazepines2.2.BarbituratesBarbiturates3.3.Dilantin or CerebyxDilantin or Cerebyx

• BENZODIAZEPINES:BENZODIAZEPINES:

–Lorazepam (Ativan)Lorazepam (Ativan)

–Midazolam (Versed)Midazolam (Versed)

–Diazepam (Valium)Diazepam (Valium)



•May be administered IV, IM, May be administered IV, IM, PO or rectally in infantsPO or rectally in infants

•Usually administered by IV Usually administered by IV infusion pump during infusion pump during interfacility transportinterfacility transport

• Barbiturate of choice for many years Barbiturate of choice for many years has been has been PHENOBARBITALPHENOBARBITAL

• DILANTINDILANTIN (phenytoin) and (phenytoin) and CEREBYXCEREBYX (fosphenytoin) are also frequently used (fosphenytoin) are also frequently used to suppress and/or control seizure to suppress and/or control seizure activityactivity


• It is not uncommon to see 2 or more It is not uncommon to see 2 or more different anticonvulsants used in different anticonvulsants used in combination during interfacility combination during interfacility transporttransport

• Doses may have to be altered during Doses may have to be altered during transport due to increased seizure transport due to increased seizure activityactivity


• What to watch for:What to watch for:

–HypotensionHypotension

–Respiratory depressionRespiratory depression

–VomitingVomiting

–Bradycardia and other Bradycardia and other dysrhythmiasdysrhythmias

– Increased seizure activityIncreased seizure activity


• Potential interventions in case of Potential interventions in case of adverse reaction:adverse reaction:

• Consider discontinuing drug or drugsConsider discontinuing drug or drugs• Consider fluids for hypotensionConsider fluids for hypotension• Support ventilations as necessarySupport ventilations as necessary• Treat dysrhythmias per Maine EMS Treat dysrhythmias per Maine EMS

protocolsprotocols• If increased seizure activity occurs, If increased seizure activity occurs,

consider increasing dosage if permitted by consider increasing dosage if permitted by transfer order or contact OLMCtransfer order or contact OLMC


ANTIDIABETICSANTIDIABETICS

• In the context of interfacility transport, In the context of interfacility transport, it is not uncommon to encounter it is not uncommon to encounter patients that require treatment with patients that require treatment with antidiabetic agentsantidiabetic agents

• In most cases, the medication that you In most cases, the medication that you will be monitoring or administering will will be monitoring or administering will be INSULIN.be INSULIN.

• Patients will generally have a Patients will generally have a diagnosis of:diagnosis of:–HyperglycemiaHyperglycemia

–Hyperglycemic comaHyperglycemic coma

–Hyperosmolar hyperglycemic Hyperosmolar hyperglycemic nonketotic comanonketotic coma


• INSULIN comes in many forms. They are INSULIN comes in many forms. They are generally either rapid, intermediate or long generally either rapid, intermediate or long acting preparations.acting preparations.

• Common names include the following:Common names include the following:– HumulinHumulin– NovolinNovolin– NPHNPH– IletinIletin– Lantus Lantus


• Administration will generally be by Administration will generally be by IV infusion in the interfacility mode IV infusion in the interfacility mode but…but…– In some long distance transfers it may In some long distance transfers it may

be necessary to administer the patient’s be necessary to administer the patient’s routine dose of insulin by subcutaneous routine dose of insulin by subcutaneous injectioninjection


• Blood glucose monitoring may be Blood glucose monitoring may be necessary depending on the patient’s necessary depending on the patient’s condition and the length of the transfercondition and the length of the transfer


• What to watch for during transport:What to watch for during transport:– Seizures Seizures

– Alterations in blood glucoseAlterations in blood glucose

– Signs and symptoms of hypoglycemiaSigns and symptoms of hypoglycemia• Nausea, anxiety, altered level of Nausea, anxiety, altered level of

consciousness, tachycardia, diaphoresisconsciousness, tachycardia, diaphoresis


• Potential interventions:Potential interventions:– Treat hypoglycemia or seizures as per Treat hypoglycemia or seizures as per

Maine EMS protocolsMaine EMS protocols

– Consider discontinuing or altering the Consider discontinuing or altering the infusion rate of insulin as per OLMCinfusion rate of insulin as per OLMC

– Provide general supportive measuresProvide general supportive measures


ANTIDYSRHYTHMICSANTIDYSRHYTHMICS

This is the largest classification This is the largest classification of medication in the PIFT of medication in the PIFT

module as it contains several module as it contains several sub-classificationssub-classifications

• Contained within this section are the Contained within this section are the following sub-classes of medications:following sub-classes of medications:– Beta BlockersBeta Blockers– Calcium Channel BlockersCalcium Channel Blockers– Cardiac GlycosidesCardiac Glycosides– Miscellaneous Antidysrhythmics such as:Miscellaneous Antidysrhythmics such as:

• Amiodarone (Cordarone)Amiodarone (Cordarone)• Magnesium sulfateMagnesium sulfate• Procainamide (Pronestyl)Procainamide (Pronestyl)• Phenytoin (Dilantin)Phenytoin (Dilantin)• Lidocaine Lidocaine


NOTENOTE

• Certain medications will appear in Certain medications will appear in several different classifications during several different classifications during this program as some of them are this program as some of them are indicated for different medical indicated for different medical conditions.conditions.– Ex. Beta blockers and calcium channel Ex. Beta blockers and calcium channel

blockers appear in this section as blockers appear in this section as antidysrhythmic agents but will also be seen antidysrhythmic agents but will also be seen in the section on Antihypertensivesin the section on Antihypertensives

• What kinds of patients will we see on What kinds of patients will we see on antidysrhythmic medications?antidysrhythmic medications?– CARDIAC PATIENTSCARDIAC PATIENTS

• Confirmed or suspected MIsConfirmed or suspected MIs• AnginaAngina• TachydysrhythmiasTachydysrhythmias• Bradydysrhythmias with or without heart blocksBradydysrhythmias with or without heart blocks• Atrial fibrillation and flutterAtrial fibrillation and flutter• PVCs and other ectopic conditionsPVCs and other ectopic conditions


BETA BLOCKERSBETA BLOCKERS

Metoprolol (Lopressor)Metoprolol (Lopressor)Propranolol (Inderal)Propranolol (Inderal)Atenolol (Tenormin)Atenolol (Tenormin)Esmolol (Brevibloc)Esmolol (Brevibloc)

• During transport primarily used to treat During transport primarily used to treat various tachydysrhythmias, atrial fibrillation various tachydysrhythmias, atrial fibrillation and atrial flutterand atrial flutter

• Used to treat MIs but generally given in Used to treat MIs but generally given in hospital prior to transferhospital prior to transfer

CALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERS

Diltiazem (Cardizem)Diltiazem (Cardizem)

Verapamil (Calan)Verapamil (Calan)

Nifedipine (Procardia)Nifedipine (Procardia)

•Treatment of tachydysrhythmias, Treatment of tachydysrhythmias, atrial fibrillation and flutteratrial fibrillation and flutter

CARDIAC GLYCOSIDESCARDIAC GLYCOSIDES

Digoxin (Lanoxin)Digoxin (Lanoxin)

• Treatment of tachydysrhythmias, Treatment of tachydysrhythmias, particularly to control ventricular particularly to control ventricular rate in atrial fibrillation or flutter; rate in atrial fibrillation or flutter;

PSVTPSVT

AMIODARONEAMIODARONE

• Generally used to treat atrial and Generally used to treat atrial and ventricular tachydysrhythmias during ventricular tachydysrhythmias during interfacility transportinterfacility transport

LIDOCAINELIDOCAINE

• Used to treat wide complex Used to treat wide complex tachycardia and ventricular ectopytachycardia and ventricular ectopy

ROUTES OF ADMINISTRATIONROUTES OF ADMINISTRATION

•Antidysrhymics will almost always Antidysrhymics will almost always be administered IV by infusion be administered IV by infusion pumppump

• WHAT TO WATCH FOR DURING WHAT TO WATCH FOR DURING TRANSPORT:TRANSPORT:

–DysrhythmiasDysrhythmias

–Altered levels of consciousnessAltered levels of consciousness

–Hypotension/changes in vital signsHypotension/changes in vital signs

–SeizuresSeizures


• Potential interventions in case of Potential interventions in case of adverse or allergic reaction:adverse or allergic reaction:– Treat dysrhythmias and seizures per Maine Treat dysrhythmias and seizures per Maine

EMS protocolsEMS protocols– Consider fluids for hypotension if not Consider fluids for hypotension if not

contraindicated by patient’s conditioncontraindicated by patient’s condition– OLMC for option of discontinuing drug, OLMC for option of discontinuing drug,

adjusting dosage or diversionadjusting dosage or diversion– General supportive measuresGeneral supportive measures


• KEEP IN MIND THAT ALL PATIENTS KEEP IN MIND THAT ALL PATIENTS ON CARDIAC MEDICATIONS SHOULD ON CARDIAC MEDICATIONS SHOULD BE TRANSPORTED ON A CARDIAC BE TRANSPORTED ON A CARDIAC MONITORMONITOR

• Record any changes in rhythmRecord any changes in rhythm

• Take frequent vitalsTake frequent vitals


• REMEMBER THAT CARDIAC PATIENTS REMEMBER THAT CARDIAC PATIENTS CAN DETERIORATE QUICKLY AND CAN DETERIORATE QUICKLY AND YOU MUST BE PREPARED FOR A YOU MUST BE PREPARED FOR A CODE OR OTHER SERIOUS EVENT AT CODE OR OTHER SERIOUS EVENT AT ALL TIMESALL TIMES


ANTI-INFECTIVESANTI-INFECTIVES

• Includes the following:Includes the following:

• AntibioticsAntibiotics

• Antivirals Antivirals

• Antifungal agentsAntifungal agents

Rarely will we see an antiviral or Rarely will we see an antiviral or antifungal agent on an interfacility antifungal agent on an interfacility

transfertransfer

• What types of patients can we expect to What types of patients can we expect to see on anti-infectives?see on anti-infectives?

• Pneumonia/respiratory infectionsPneumonia/respiratory infections• MeningitisMeningitis• SepsisSepsis• CellulitisCellulitis• UTIUTI• Various infectious diseasesVarious infectious diseases


• Most common medications used in Most common medications used in transport:transport:

• VancomycinVancomycin

• RocephinRocephin

• PenicillinPenicillin

• Cefazolin (Ancef)Cefazolin (Ancef)

• GentamicinGentamicin


Almost always administered IVAlmost always administered IV


• What to look for:What to look for:• Signs and symptoms of allergic Signs and symptoms of allergic

reactionreaction

• Induration or redness at the IV siteInduration or redness at the IV site

• Altered level of consciousnessAltered level of consciousness

• Nausea/vomitingNausea/vomiting


• Note:Note:– Antibiotics have a greater potential Antibiotics have a greater potential

for allergic reactions than any other for allergic reactions than any other drugsdrugs


ANTIHYPERTENSIVESANTIHYPERTENSIVES

• These medications are essentially used to These medications are essentially used to control hypertensive crisis of various control hypertensive crisis of various etiologiesetiologies

• Included within the classification of Included within the classification of antihypertensives are several other antihypertensives are several other classes of medications that have classes of medications that have antihypertensive actionantihypertensive action

• Other classifications and subclassifications Other classifications and subclassifications of antihypertensives include:of antihypertensives include:– ACE InhibitorsACE Inhibitors– Beta BlockersBeta Blockers– Alpha BlockersAlpha Blockers– Calcium Channel BlockersCalcium Channel Blockers– DiureticsDiuretics– VasodilatorsVasodilators


COMMONLY USED COMMONLY USED ANTIHYPERTENSIVESANTIHYPERTENSIVES

COMMONLY USED COMMONLY USED ANTIHYPERTENSIVESANTIHYPERTENSIVES

• ACE InhibitorsACE Inhibitors• Benazepril (Lotensin)Benazepril (Lotensin)

• Enalapril (Vasotec)Enalapril (Vasotec)

• Lisinopril (Zestril)Lisinopril (Zestril)

• Captopril (Capoten)Captopril (Capoten)

• Alpha BlockersAlpha Blockers

–Doxazosin (Cardura)Doxazosin (Cardura)

–Prazosin (Minipress)Prazosin (Minipress)

–Terazosin (Hytrin)Terazosin (Hytrin)


• Beta BlockersBeta Blockers– Atenolol (Tenormin)Atenolol (Tenormin)

– Propranolol (Inderal)Propranolol (Inderal)

– Metoprolol (Lopressor)Metoprolol (Lopressor)

– Labetalol (Normodyne)Labetalol (Normodyne)


• Calcium Channel BlockersCalcium Channel Blockers– Diltiazem (Cardizem)Diltiazem (Cardizem)

– Verapamil (Calan)Verapamil (Calan)

– Nifedipine (Procardia)Nifedipine (Procardia)

– Amlodipine (Norvasc)Amlodipine (Norvasc)


• DiureticsDiuretics–Furosemide (Lasix)Furosemide (Lasix)

–Bumetadine (Bumex)Bumetadine (Bumex)

–Torsemide (Demadex)Torsemide (Demadex)


• VasodilatorsVasodilators–Hydralazine (Apresoline)Hydralazine (Apresoline)

–Minoxidil (Loniten)Minoxidil (Loniten)

–NitroglycerinNitroglycerin


• Routes of Administration:Routes of Administration:– Generally IV but may be given PO in Generally IV but may be given PO in

certain cases on long transferscertain cases on long transfers


• What to watch for during transportWhat to watch for during transport

–Severe hypotensionSevere hypotension

–Nausea/vomitingNausea/vomiting

–Symptomatic bradycardiaSymptomatic bradycardia

–Other dysrhythmiasOther dysrhythmias


• Possible interventions when adverse Possible interventions when adverse reactions occur during transport:reactions occur during transport:

– Treat bradycardia and other Treat bradycardia and other dysrhythmias as per Maine EMS dysrhythmias as per Maine EMS protocolsprotocols

– Consider fluids for hypotension if not Consider fluids for hypotension if not contraindicated by patient conditioncontraindicated by patient condition


• Possible Interventions when adverse Possible Interventions when adverse reactions occur during transport:reactions occur during transport:

– Consider promethazine ( Phenergan ) Consider promethazine ( Phenergan ) for nauseafor nausea

– Contact OLMC for options of Contact OLMC for options of discontinuing medication, altering discontinuing medication, altering dosage or diversiondosage or diversion


• All patients on antihypertensive All patients on antihypertensive medications should be medications should be transferred on a cardiac transferred on a cardiac monitormonitor

• Take frequent vitalsTake frequent vitals


BREAKBREAK

SCENARIO 1SCENARIO 1

• You are transporting a cardiac patient from a You are transporting a cardiac patient from a local community hospital to Eastern Maine local community hospital to Eastern Maine Medical Center. The patient has a diagnosis Medical Center. The patient has a diagnosis of unstable angina. Transport time to EMMC of unstable angina. Transport time to EMMC is approximately 90 minutes.is approximately 90 minutes.

• As you left the sending facility, the patient As you left the sending facility, the patient had the following vitals:had the following vitals:

• HR---76HR---76 BP---122/76 R---18BP---122/76 R---18

• MedicationsMedications– Oxygen at 4 lpm via ncOxygen at 4 lpm via nc– Nitroglycerine IV 14 mcg/minNitroglycerine IV 14 mcg/min– Heparin IV 1000u/hourHeparin IV 1000u/hour– Aggrastat IV 80mcg/minAggrastat IV 80mcg/min– You also have orders for Morphine 2-5 mg You also have orders for Morphine 2-5 mg

prn for pain managementprn for pain management


• 30 minutes into the transfer your 30 minutes into the transfer your patient begins to appear anxious, patient begins to appear anxious, becomes slightly diaphoretic, and becomes slightly diaphoretic, and complains of some SOB. complains of some SOB.

• You take a new set of vitals:You take a new set of vitals:

– HR---104HR---104

– BP---96/62BP---96/62

– R-----20R-----20


1.1. What do you suspect?What do you suspect?

2.2. What action would you take?What action would you take?

3.3. What questions do you have What questions do you have for medical control?for medical control?


ANTIPSYCHOTICSANTIPSYCHOTICS

• The number of psychiatric transfers The number of psychiatric transfers has increased dramatically in recent has increased dramatically in recent yearsyears

• A many patients are transferred with A many patients are transferred with chemical restraints and sometimes chemical restraints and sometimes need to be given additional medication need to be given additional medication during transportduring transport

• Medication is administered to control Medication is administered to control psychotic behavior that is otherwise psychotic behavior that is otherwise difficult to manage in an ambulancedifficult to manage in an ambulance

• Patients will have a number of different Patients will have a number of different diagnoses including agitation, diagnoses including agitation, schizophrenia, depression, delusional schizophrenia, depression, delusional disorders, etc.disorders, etc.


A number of different A number of different medications are used to medications are used to

provide chemical restraintprovide chemical restraint


• Common Chemical Restraint Common Chemical Restraint Medications:Medications:– Haloperidol (Haldol)Haloperidol (Haldol)

– Chlorpromazine (Thorazine)Chlorpromazine (Thorazine)

– Risperidone (Risperdal)Risperidone (Risperdal)

– Benzodiazepines (Diazepam, Benzodiazepines (Diazepam, Lorazepam, Midazolam)Lorazepam, Midazolam)

CHEMICAL RESTRAINTCHEMICAL RESTRAINT

• These drugs may be given alone or in These drugs may be given alone or in combination with other antipsychotic combination with other antipsychotic drugsdrugs

• May also be administered in May also be administered in combination with other medications combination with other medications such as diphenhydramine (Benadryl) such as diphenhydramine (Benadryl) for added sedative effectfor added sedative effect

CHEMICAL RESTRAINTCHEMICAL RESTRAINT

• Routes of administrationRoutes of administration– Generally given IV but may be given IM Generally given IV but may be given IM

or PO in some casesor PO in some cases

– For IV medication, the patient should For IV medication, the patient should leave the hospital with a saline lock in leave the hospital with a saline lock in place if possibleplace if possible


• Considerations…Considerations…– Discuss all medication issues with the Discuss all medication issues with the

sending physician before leaving the sending physician before leaving the hospitalhospital

– If the patient is sedated upon your arrival, If the patient is sedated upon your arrival, ask if the drug will last long enough for ask if the drug will last long enough for you to reach your destinationyou to reach your destination• Transfers of more than 2 hours are not Transfers of more than 2 hours are not

uncommonuncommon


• Considerations…Considerations…– If medication will be needed during If medication will be needed during

transport, do not wait until the patient transport, do not wait until the patient becomes disruptive and combativebecomes disruptive and combative

– Make sure that any patient who is Make sure that any patient who is medicated or may require medication medicated or may require medication during transport is “Blue papered”during transport is “Blue papered”


• What to watch for during transport:What to watch for during transport:



–SeizuresSeizures

–Extrapyramidal reactionsExtrapyramidal reactions• Agitation, muscle tremor, drooling, Agitation, muscle tremor, drooling,

tremors, etc.tremors, etc.


• Potential interventions in cases of Potential interventions in cases of adverse or allergic reactions:adverse or allergic reactions:– Treat allergic reactions and seizures as per Treat allergic reactions and seizures as per

Maine EMS protocolsMaine EMS protocols– Support ventilations as necessary and be Support ventilations as necessary and be

prepared to intubateprepared to intubate– Consider fluids for hypotensionConsider fluids for hypotension– Diphenhydramine for extrapyramidal reactionsDiphenhydramine for extrapyramidal reactions– OLMC for other options including diversionOLMC for other options including diversion



• These are essentially digitalis These are essentially digitalis preparationspreparations

– The most commonly used drug is digoxin The most commonly used drug is digoxin (Lanoxin)(Lanoxin)

– Generally used to treat atrial fibrillation, Generally used to treat atrial fibrillation, atrial flutter or atrial tachycardiasatrial flutter or atrial tachycardias

– Sometimes used to treat CHFSometimes used to treat CHF

Route of Administration:Route of Administration:

• Generally IV infusionGenerally IV infusion



–Dysrhythmias including heart blocksDysrhythmias including heart blocks

–Cardiac arrestCardiac arrest


–Digitalis toxicityDigitalis toxicity


• Potential interventions for adverse Potential interventions for adverse reactions:reactions:– Treat all dysrhythmias per Maine EMS Treat all dysrhythmias per Maine EMS

protocolsprotocols– Consider promethazine for Consider promethazine for

nausea/vomitingnausea/vomiting– Contact OLMC for options of Contact OLMC for options of

discontinuing drug, altering dose or discontinuing drug, altering dose or diversiondiversion


• All patients on cardiac glycosides All patients on cardiac glycosides must be transported on a cardiac must be transported on a cardiac monitor and watched carefully for monitor and watched carefully for developing adverse reactionsdeveloping adverse reactions


CORTICOSTEROIDSCORTICOSTEROIDS

• Medications in this class are primarily Medications in this class are primarily used to treat the following:used to treat the following:– Cerebral edema associated with head injuryCerebral edema associated with head injury– Status asthmaticusStatus asthmaticus– To suppress the immune system in cases of To suppress the immune system in cases of

severe allergic reactions/anaphylactic shocksevere allergic reactions/anaphylactic shock– Chronic inflammatory conditionsChronic inflammatory conditions

• Routes of administration:Routes of administration:– IV infusion in most casesIV infusion in most cases

– Also used in inhaled form for certain Also used in inhaled form for certain respiratory conditionsrespiratory conditions


• Commonly used medications in Commonly used medications in this classthis class– Betamethasone (Celestone)Betamethasone (Celestone)

– Dexamethasone (Decadron)Dexamethasone (Decadron)

– Methylprednisolone (Solu-Medrol)Methylprednisolone (Solu-Medrol)

– Hydrocortisone (Solu-Cortef)Hydrocortisone (Solu-Cortef)


• Also in inhaled form…Also in inhaled form…– Beclomethasone (Beconase, Beclovent)Beclomethasone (Beconase, Beclovent)

– Triamcinolone (Azmacort, Kenalog)Triamcinolone (Azmacort, Kenalog)

– Flunisolide (Aerobid)Flunisolide (Aerobid)


• What to watch for during What to watch for during transport:transport:–HypertensionHypertension


–CHFCHF


• Potential interventions in case of Potential interventions in case of adverse reactionsadverse reactions::– Follow Maine EMS protocols for allergic Follow Maine EMS protocols for allergic

reactions, CHF or nausea/vomitingreactions, CHF or nausea/vomiting

– Contact OLMC for options of Contact OLMC for options of discontinuing drugdiscontinuing drug


DROTRECOGINDROTRECOGIN

• An antisepsis agentAn antisepsis agent

• Used to treat severe sepsis or septic Used to treat severe sepsis or septic shockshock

• Administered by IV infusion onlyAdministered by IV infusion only

• What to watch for during What to watch for during transporttransport::–Be alert for signs of internal Be alert for signs of internal

bleedingbleeding

–Shock symptomsShock symptoms


• Potential interventions during Potential interventions during transport :transport :–Treat for shock Treat for shock

–Contact OLMC for option of Contact OLMC for option of discontinuing drugdiscontinuing drug


GASTROINTESTINAL AGENTSGASTROINTESTINAL AGENTS

• Used to treat a variety of GI Used to treat a variety of GI disordersdisorders

• Several different sub-Several different sub-classifications of GI medications:classifications of GI medications:

1.1. Proton Pump InhibitorsProton Pump Inhibitors2.2. Somatostatin AnaloguesSomatostatin Analogues3.3. H2 BlockersH2 Blockers4.4. Anti-emeticsAnti-emetics

• Commonly used drugs:Commonly used drugs:

–Protonix Protonix

–PrevacidPrevacid

Protein Pump InhibitorsProtein Pump Inhibitors

• Commonly used drug:Commonly used drug:

–SandostatinSandostatin

Somatostatin AnaloguesSomatostatin Analogues

• Commonly used drug:Commonly used drug:–Famotidine (Pepcid)Famotidine (Pepcid)

–Cometidine (Tagamet)Cometidine (Tagamet)

H2 BlockersH2 Blockers

Anti-emetics

• metoclopramide (Reglan)metoclopramide (Reglan)

• ondansetron (Zofran)ondansetron (Zofran)

• prochlorperazine (Compazine)prochlorperazine (Compazine)

• What kind of patients will we see being What kind of patients will we see being transported on these medications?transported on these medications?

– Active duodenal or gastric ulcersActive duodenal or gastric ulcers

– GERD—gastric esophageal reflux GERD—gastric esophageal reflux diseasedisease

– Upper GI bleedUpper GI bleed

– Esophageal varicesEsophageal varices


• Routes of Administration:Routes of Administration:

– IV infusionIV infusion

–POPO



–Adverse reactions are rare but may Adverse reactions are rare but may consist of dysrhythmiasconsist of dysrhythmias

–Hypoglycemia is possible but will Hypoglycemia is possible but will probably only be seen on longer probably only be seen on longer transferstransfers


• Potential interventions for adverse Potential interventions for adverse or allergic reactions:or allergic reactions:– Treat dysrhythmias and hypoglycemia Treat dysrhythmias and hypoglycemia

per Maine EMS protocolsper Maine EMS protocols

– Consider termination of drugConsider termination of drug

– OLMC for further optionsOLMC for further options


IV FLUIDSIV FLUIDS

• Consists of a wide variety of fluids Consists of a wide variety of fluids including the following:including the following:

– Normal saline, ½ NSNormal saline, ½ NS

– Lactated Ringers Lactated Ringers

– DD55W and DW and D1010WW

– Dextran, PlasmanateDextran, Plasmanate

– Hetastarch, albuminHetastarch, albumin

• Why do we give IV fluids during Why do we give IV fluids during transport?transport?

– Increase or maintain blood volume and Increase or maintain blood volume and blood pressureblood pressure

– Maintain hydrationMaintain hydration

– Access for medicationAccess for medication

– Treat hypoglycemia (DTreat hypoglycemia (D1010W)W)

IV FLUIDSIV FLUIDS


–Signs of fluid overloadSigns of fluid overload

–EdemaEdema

–Pulmonary edemaPulmonary edema

–Take vitals often to monitor BPTake vitals often to monitor BP

IV FLUIDSIV FLUIDS

• Potential interventions in cases of Potential interventions in cases of adverse reactions:adverse reactions:

–Consider discontinuing or reducing Consider discontinuing or reducing rate of infusionrate of infusion

–Treat CHF per Maine EMS Treat CHF per Maine EMS protocolsprotocols

IV FLUIDSIV FLUIDS

ELECTROLYTESELECTROLYTES

• Electrolytes consist of the following:Electrolytes consist of the following:

– PotassiumPotassium

– CalciumCalcium

– Sodium chlorideSodium chloride

– Sodium bicarbonate (alkalizing agent)Sodium bicarbonate (alkalizing agent)

• What type of patients will we see who What type of patients will we see who require electrolyte therapy?require electrolyte therapy?

– Patients requiring potassium Patients requiring potassium supplementation due to deficiency supplementation due to deficiency diseases when oral replacement is not diseases when oral replacement is not feasiblefeasible

– Those who have lost potassium due to Those who have lost potassium due to severe vomiting or diarrheasevere vomiting or diarrhea


• What type of patients will we see who What type of patients will we see who require electrolyte therapy?require electrolyte therapy?

– Patients with severe hypocalcemiaPatients with severe hypocalcemia

– Sodium depletionSodium depletion

– Patients requiring sodium bicarbonate to Patients requiring sodium bicarbonate to treat hyperacidity or metabolic acidosis treat hyperacidity or metabolic acidosis due to shock or dehydrationdue to shock or dehydration


• Route of administration:Route of administration:–Primarily Primarily IV infusionIV infusion


• What to watch for during transport:What to watch for during transport:– DysrhythmiasDysrhythmias

– SeizuresSeizures

– Signs and symptoms of allergic Signs and symptoms of allergic reactions (rare)reactions (rare)


• Potential interventions in cases of Potential interventions in cases of adverse reactions:adverse reactions:– Treat seizures and dysrhythmias per Treat seizures and dysrhythmias per

Maine EMS protocolsMaine EMS protocols

– Consider option of discontinuing drug or Consider option of discontinuing drug or modifying dose as per OLMC or transfer modifying dose as per OLMC or transfer ordersorders


NARCOTICSNARCOTICS

• Used to control moderate to severe Used to control moderate to severe painpain

• May be administered by IV infusion May be administered by IV infusion pump but may also be given by IV or IM pump but may also be given by IV or IM injection as per transfer orderinjection as per transfer order

• Commonly used narcotics:Commonly used narcotics:

–FentanylFentanyl

–MorphineMorphine

–Hydromorphone (Dilaudid)Hydromorphone (Dilaudid)

–Meperidine (Demerol)Meperidine (Demerol)

–Pentazocine (Talwin)Pentazocine (Talwin)

NARCOTICSNARCOTICS





–BradycardiaBradycardia

NARCOTICSNARCOTICS

• Potential interventions in cases of Potential interventions in cases of adverse reactions:adverse reactions:– Consider discontinuing medicationConsider discontinuing medication

– Treat dysrhythmias per Maine EMS Treat dysrhythmias per Maine EMS protocolsprotocols

– Consider Naloxone Consider Naloxone

– Assist ventilations as necessary and be Assist ventilations as necessary and be prepared to intubateprepared to intubate

NARCOTICSNARCOTICS

PARENTERAL NUTRITIONPARENTERAL NUTRITION

• Used to treat the following:Used to treat the following:

– Patients requiring nutrition who are Patients requiring nutrition who are unable to take food and/or fluids by unable to take food and/or fluids by mouthmouth

– Patients requiring vitamin supplements Patients requiring vitamin supplements to prevent or treat vitamin deficiency to prevent or treat vitamin deficiency conditionsconditions

• Common forms include the following:Common forms include the following:

– Vitamin solutionsVitamin solutions

– TPN (Total Parenteral Nutrition)TPN (Total Parenteral Nutrition)• An individualized solution designed to meet An individualized solution designed to meet

the needs of the patientthe needs of the patient


• What to watch for during transport:What to watch for during transport:– Adverse or allergic reactions are rare Adverse or allergic reactions are rare

but have been seenbut have been seen

– Hypoglycemia Hypoglycemia • Can occur since most TPN preparations Can occur since most TPN preparations

contain Insulincontain Insulin


• Potential interventions in case of Potential interventions in case of adverse reactions:adverse reactions:– Treat hypoglycemia as per Maine EMS Treat hypoglycemia as per Maine EMS

protocolsprotocols

– Consider discontinuing drugConsider discontinuing drug


GLYCOPROTEINGLYCOPROTEINIIb/IIa Platelet InhibitorsIIb/IIa Platelet Inhibitors

• What are these drugs all about? What are these drugs all about? – They are potent agents that inhibit They are potent agents that inhibit

platelets from aggregating or clumping platelets from aggregating or clumping together in the context of coronary together in the context of coronary artery disease. artery disease.

– Frequently used in combination with Frequently used in combination with HeparinHeparin

• Patients being transported on these Patients being transported on these drugsdrugs

– Acute MIAcute MI– Unstable anginaUnstable angina– Acute coronary syndromeAcute coronary syndrome– Many of these patients are being transported Many of these patients are being transported

to the cath lab for diagnostic and/or to the cath lab for diagnostic and/or interventional catherization---angioplastyinterventional catherization---angioplasty


• Route of Administration:Route of Administration:

–IV infusion onlyIV infusion only


• What to watch for during transport:What to watch for during transport:– Any signs of bleedingAny signs of bleeding

– Signs and symptoms of shockSigns and symptoms of shock

– Changes in level of consciousnessChanges in level of consciousness


• Potential interventions in cases of Potential interventions in cases of adverse or allergic reactions:adverse or allergic reactions:– Control any external bleedingControl any external bleeding– Treat for shock as neededTreat for shock as needed– Contact OLMC for options of discontinuing Contact OLMC for options of discontinuing

drug, altering dose or diversiondrug, altering dose or diversion– In cases of suspected bleeding, the provider In cases of suspected bleeding, the provider

may also have to D/C heparin if it is also may also have to D/C heparin if it is also being administeredbeing administered

– Treat dysrhythmias and allergic reactions as Treat dysrhythmias and allergic reactions as per Maine EMS protocolsper Maine EMS protocols


MULTIPLE MEDICATIONSMULTIPLE MEDICATIONS

• Keep in mind that you will often be Keep in mind that you will often be transporting patients on 2, 3 or even transporting patients on 2, 3 or even more medicationsmore medications– Eg.: Eg.: It is common to transport a cardiac It is common to transport a cardiac

patient on patient on nitroglycerinnitroglycerin, , HeparinHeparin and and AggrastatAggrastat with an order to administer with an order to administer FentanylFentanyl for pain as needed.for pain as needed.


• We have discussed the option of We have discussed the option of diversiondiversion to a nearby hospital in almost to a nearby hospital in almost each of the classifications that we have each of the classifications that we have examinedexamined

• This is often a difficult decision to This is often a difficult decision to make for a number of reasonsmake for a number of reasons

• What are the potential benefits of What are the potential benefits of diversion?diversion?

• What are the potential negative aspects What are the potential negative aspects of diversion?of diversion?

• What factors should be considered in What factors should be considered in deciding to divert?deciding to divert?

• Can you divert without authorization Can you divert without authorization from OLMC?from OLMC?


• DIVERSION CONSIDERATIONSDIVERSION CONSIDERATIONS– Patient conditionPatient condition– Transfer ordersTransfer orders– Ability to treat Ability to treat – Distance to receiving or sending Distance to receiving or sending

facilityfacility– Consult with OLMCConsult with OLMC– Comfort level of paramedicComfort level of paramedic


RESPIRATORY MEDICATIONSRESPIRATORY MEDICATIONS

• Within this classification are several Within this classification are several subclassifications of drugs that are used in subclassifications of drugs that are used in treating patients with respiratory conditionstreating patients with respiratory conditions– Beta agonistsBeta agonists– AnticholinergicsAnticholinergics– Steroids Steroids – MucolyticsMucolytics

– MiscellaneousMiscellaneous

• Albuterol (Proventil) Albuterol (Proventil)

• TerbutalineTerbutaline

• Metaproterenol (Alupent)Metaproterenol (Alupent)

• Piruterol (Maxair)Piruterol (Maxair)

BETA AGONISTSBETA AGONISTS

These drugs provide relief through bronchodilationThese drugs provide relief through bronchodilation

ANTICHOLINERGICSANTICHOLINERGICS

• Ipratropium (Atrovent) Ipratropium (Atrovent)

These drugs provide long term These drugs provide long term maintenance of bronchodilationmaintenance of bronchodilation

STEROIDSSTEROIDS

• Beclomethasone (Beclovent)Beclomethasone (Beclovent)

• Flunisolide (AeroBid)Flunisolide (AeroBid)

• Fluticasone (Flovent)Fluticasone (Flovent)

• Triamcinolone (Azmacort)Triamcinolone (Azmacort)

These drugs provide relief by reducing These drugs provide relief by reducing inflammationinflammation

MISCELLANEOUSMISCELLANEOUS

• AminophyllineAminophylline

• Montelukast (Singulair)Montelukast (Singulair)

• What kinds of patients will you be What kinds of patients will you be transporting on respiratory transporting on respiratory medications?medications?– The respiratory problem may be primary or The respiratory problem may be primary or

secondarysecondary– Acute or chronicAcute or chronic


• AsthmaAsthma

• COPDCOPD

• EmphysemaEmphysema

• Certain cases of allergic reactionCertain cases of allergic reaction


• Routes of administration:Routes of administration:

– Most of these drugs will be administered Most of these drugs will be administered by inhaler or nebulizedby inhaler or nebulized• Aminophylline is given by IV infusionAminophylline is given by IV infusion• Terbutaline may be IV or by inhalationTerbutaline may be IV or by inhalation• Is epinephrine a respiratory medication?Is epinephrine a respiratory medication?


• Transport respiratory medication Transport respiratory medication patients on cardiac monitorpatients on cardiac monitor



–DysrhythmiasDysrhythmias• Beta agonists such as Albuterol can Beta agonists such as Albuterol can

cause tachydysrhythmiascause tachydysrhythmias

–Palpitations, chest painPalpitations, chest pain


• Potential interventions in case Potential interventions in case of adverse reaction:of adverse reaction:–Treat dysrhythmias and chest pain Treat dysrhythmias and chest pain

per Maine EMS protocolsper Maine EMS protocols


SEDATIVESSEDATIVES

• Sedatives consist of a variety of Sedatives consist of a variety of medications from several different medications from several different classifications classifications (Some that we have (Some that we have already reviewed)already reviewed)– NarcoticsNarcotics– BenzodiazepinesBenzodiazepines– AntipsychoticsAntipsychotics– Barbiturates and anestheticsBarbiturates and anesthetics

• NarcoticsNarcotics– Fentanyl, morphine, dilaudid, meperidine, etc.Fentanyl, morphine, dilaudid, meperidine, etc.

• BenzodiazepinesBenzodiazepines – Diazepam, lorazepam, midazolamDiazepam, lorazepam, midazolam

• AntipsychoticsAntipsychotics– Haloperidol, risperidone, chlorpromazine, etc.Haloperidol, risperidone, chlorpromazine, etc.

• BarbituratesBarbiturates– Phenobarbital, thiopental, amobarbitalPhenobarbital, thiopental, amobarbital

• AnestheticsAnesthetics– Etomidate, propofolEtomidate, propofol

SEDATIVESSEDATIVES

• NOTE:NOTE: Paramedics will not Paramedics will not transport patients on anesthetics transport patients on anesthetics unless accompanied by an RNunless accompanied by an RN– Most patients on anesthetics are Most patients on anesthetics are

intubatedintubated

SEDATIVESSEDATIVES

• Types of patients on sedatives…Types of patients on sedatives…– Agitation and combativeness associated Agitation and combativeness associated

with head injury, psychosis, etc.with head injury, psychosis, etc.

– Control of seizure activityControl of seizure activity

– Any condition where it is necessary to Any condition where it is necessary to provide sedationprovide sedation

SEDATIVESSEDATIVES




–BradycardiaBradycardia

SEDATIVESSEDATIVES

• Potential interventions in cases of Potential interventions in cases of adverse reactions:adverse reactions:– Oxygen, Support ventilations as Oxygen, Support ventilations as

necessary and be prepared to intubatenecessary and be prepared to intubate

– Treat bradycardia per Maine EMS Treat bradycardia per Maine EMS protocolsprotocols

– Consider fluids for hypotensionConsider fluids for hypotension

– OLMC for other optionsOLMC for other options

SEDATIVESSEDATIVES

• Take vitals oftenTake vitals often

• Transport on cardiac monitorTransport on cardiac monitor

SEDATIVESSEDATIVES

VASOACTIVE AGENTSVASOACTIVE AGENTS

• These are medications that have an These are medications that have an effect on the tone and caliber or effect on the tone and caliber or diameter of blood vesselsdiameter of blood vessels– Vasopressors and sympathomimetic drugs Vasopressors and sympathomimetic drugs

cause constriction of blood vessels…….cause constriction of blood vessels…….– Nitrates, vasodilators, Calcium Channel Nitrates, vasodilators, Calcium Channel

Blockers and ACE Inhibitors cause relaxation Blockers and ACE Inhibitors cause relaxation and dilation of vessels, thereby reducing BPand dilation of vessels, thereby reducing BP

• What kinds of patients will we see on What kinds of patients will we see on Vasopressors and Sympathomimetics?Vasopressors and Sympathomimetics?

– Patients on these drugs are generally Patients on these drugs are generally being treated for hypotension and being treated for hypotension and certain types of shockcertain types of shock


• Commonly used vasopressors and Commonly used vasopressors and sympathomimetics:sympathomimetics:– Vasopressin (Pitressin)Vasopressin (Pitressin)– Metaraminol (Aramine)Metaraminol (Aramine)– Dopamine (Intropin)Dopamine (Intropin)– Dobutamine (Dobutrex)Dobutamine (Dobutrex)– Epinephrine and norepinephrineEpinephrine and norepinephrine– Isoproterenol (Isuprel)Isoproterenol (Isuprel)


• Patients taking nitrates are generally Patients taking nitrates are generally being treated for ischemic chest being treated for ischemic chest pain or hypertensive crisispain or hypertensive crisis

NITRATESNITRATES

NITRATESNITRATES

• Commonly used nitrates include:Commonly used nitrates include:– NitroglycerinNitroglycerin

– Nitroprusside (Nipride)Nitroprusside (Nipride)

VASODILATORSVASODILATORS

• Used primarily for treatment of Used primarily for treatment of hypertensive crisis and hypertensive crisis and management of CHFmanagement of CHF

• Calcium Channel Blockers and ACE Calcium Channel Blockers and ACE Inhibitors are primarily used to treat Inhibitors are primarily used to treat hypertension as we saw in the section hypertension as we saw in the section on Antihypertensiveson Antihypertensives


• Routes of administration:Routes of administration:

–IV infusionIV infusion• Usually by infusion pumpUsually by infusion pump



–Severe hypotension or Severe hypotension or hypertensionhypertension

–DysrhythmiasDysrhythmias

–DyspneaDyspnea

–Altered level of consciousnessAltered level of consciousness



• Potential interventions in case of Potential interventions in case of adverse or allergic reactions:adverse or allergic reactions:– Treat dysrhythmias as per Maine EMS Treat dysrhythmias as per Maine EMS

protocolsprotocols– Consider fluids for hypotensionConsider fluids for hypotension– Consider discontinuing drug or modifying Consider discontinuing drug or modifying

dose as per OLMC or transfer orderdose as per OLMC or transfer order– DiversionDiversion


• NOTE:NOTE:

– These patients must be transported on a These patients must be transported on a cardiac monitorcardiac monitor

– Monitor vitals frequentlyMonitor vitals frequently


OTC MEDICATIONSOTC MEDICATIONS

• During the course of a transport, During the course of a transport, particularly a long distance transfer, it particularly a long distance transfer, it may be necessary to administer certain may be necessary to administer certain commonly used OTC medicationscommonly used OTC medications

• May include medications for the May include medications for the following:following:

• Pain (Ibuprofen, acetaminophen, etc.)Pain (Ibuprofen, acetaminophen, etc.)

• Motion sickness (Dramamine)Motion sickness (Dramamine)

• Antacids Antacids

• Antihistamines Antihistamines


• Guidelines for administration:Guidelines for administration:– Written order by physician that includes Written order by physician that includes

name of drug, route of administration, name of drug, route of administration, indication, dose and time of initial and indication, dose and time of initial and repeat dosingrepeat dosing

– Drug must be supplied by the sending Drug must be supplied by the sending facilityfacility

– Drug must have been used previously by Drug must have been used previously by patient without adverse reactionspatient without adverse reactions


• Administration must be documented as Administration must be documented as with all other medicationswith all other medications

• Remember that even OTC drugs can Remember that even OTC drugs can result in adverse or allergic reactions result in adverse or allergic reactions so watch for any such reactions so watch for any such reactions following administrationfollowing administration


PRESCRIPTION DRUGSPRESCRIPTION DRUGS

• During longer transports you may need During longer transports you may need to administer one or more of the to administer one or more of the patient’s regular prescription drugspatient’s regular prescription drugs

• The drug must be included in one of The drug must be included in one of the classifications that are part of the the classifications that are part of the PIFT modulePIFT module

CONCLUSIONSCONCLUSIONS

• Be constantly alert—patients can Be constantly alert—patients can change in secondschange in seconds

• Know your drugs---use resourcesKnow your drugs---use resources

• Remember that every drug, even OTC Remember that every drug, even OTC drugs, have the potential to result in a drugs, have the potential to result in a serious adverse reactionserious adverse reaction


• Never leave the sending facility unless Never leave the sending facility unless you feel thoroughly comfortable with you feel thoroughly comfortable with your patient and with the medications your patient and with the medications you are being asked to administer or you are being asked to administer or monitormonitor

• Make sure that you are thoroughly Make sure that you are thoroughly prepared for any complicationprepared for any complication

• Know where possible diversion Know where possible diversion hospitals are locatedhospitals are located

• Use OLMC whenever necessaryUse OLMC whenever necessary


Questions?Questions?

Paramedic Inter Facility Transfer Training MEDICATION CLASSIFICATIONS.

Documents

sq slide

pift program slide

anticoagulants mi

paramedic medications

used anticoagulants

otc medications

mems protocol slide

paramedicmost pift medications