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October 2016: Adrenal Corticosteroids
When adrenal glands are functioning properly they synthesize and excrete various corticosteroids. These corticosteroids have several functions, including: promoting normal metabolism; increasing resistance to stress by raising plasma glucose levels to increase energy; altering blood cell levels in plasma (move lymphocytes to lymph tissue and increase hemoglobin, erythrocytes and platelets); reduce inflammatory response and suppress immunity and; help in controlling water volume and electrolyte balance.
Semisynthetic derivatives of glucocorticoids vary in their anti-inflammatory potency, the degree to which they cause sodium retention and their duration of action.
They are prescribed for various reasons including:
Mycek, M.J., Harvey, R.A., Champe, P.C. (1997). Pharmacology 2nd Ed. (ed. Harvey & Champe). Lippincott-Raven: Philadelphia.
Mayo Clinic website (2016). Mayo Foundation for Medical Education and Research. Retrieved from www.mayoclinic.org
May 2016: Antihypertensives
Lifestyle modification is the first recommendation for managing hypertension. Medications are prescribed with consideration given to causes, contraindications and comorbidities and may include:
Cause a loss of excess salt and water from the body by the kidneys with resulting drop in preload, stroke volume, and eventually peripheral vascular resistance.
Decrease cardiac output and inhibit renin-angiotension-aldosterone system that raises blood pressure through sodium and water retention.
Angiotensin Receptor Blockers (ARB):
Blocks renin-angiotensin-aldosterone (as above).
Calcium Channel Blockers (CCB):
Reduce peripheral vascular resistance by inhibiting the contractility of vascular smooth muscle.
The specific medication prescribed varies depending on underlying comorbiditiies:
Madhur, M.S. (2014). Hypertension. Retrieved from http://emedicine.medscape.com/article/241381-overview
Sanders, M. (2007). Mosby’s Paramedic Textbook Revised Third Edition. Missouri: Elselvier.
March 2016: Anti-Anxiety
Anxiety may influence a person’s life in various and sometimes coexisting forms such as phobia, social anxiety disorder, generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD). Individuals living with anxiety may have concurrent challenges with addiction, stigmatization and marginalization which can further undermine effective self-advocacy.
Approaches to managing anxiety may include short term strategies like using benzodiazepines for immediate crisis management and longer term strategies like prescription of selective serotonin reuptake inhibitors (SSRIs) and cognitive behavior therapy.
Benzodiazepines (examples below) lower neural excitability in the CNS causing anxiolysis, sedation/hypnosis, anticonvulsant effects and muscle relaxation (Mycek, 1997). They can provide a short-term fix for anxiety however they bring risks of addiction, altered affect and respiratory depression. Because benzodiazepines may be prescribed for use during crises there is an inherent risk (carefully weighed by prescriber) of intentional or accidental overdose. Sedation and respiratory depression are the key components of a benzo overdose.
SSRIs (examples below) inhibit serotonin reuptake which allows an accumulation of and functional increase in the amount of serotonin at the presynaptic nerve terminals in the brain (Mycek, 1997). SSRIs generally take 4-6 weeks of daily use to reveal their intended effects, and may be prescribed for anxiety, depression or both, or for other conditions. SSRIs have a wide therapeutic window but overdose can have a lethal outcome either through serotonin syndrome, serotonin toxicity or due to co-ingestion of other agents. Signs and symptoms of an SSRI overdose are confusion, agitation, ataxia, fever, tremor, muscle rigidity and vitals may reveal hypertension, hyperthermia, tachycardia +/- wide QT, diaphoresis and pupil dilation. Care is supportive with an emphasis on consideration of co-ingestions, and the concurrent management/reversal of those effects prn (Cushing, 2015).
Cushing, T. (2015). Selective Serotonin Reuptake Inhibitor Toxicity Clinical Presentation. Medscape. Retrieved from http://emedicine.medscape.com/article/821737-overview
Gresham, C. (2015). Benzodiazepine Toxicity Treatment & Management. Medscape. Retrieved from http://emedicine.medscape.com/article/813255-treatment
Mycek, M.J., Harvey, R.A., Champe, P.C. (1997). Lippincott’s Illustrated Reviews: Pharmacology, 2nd ed. Lippincott-Raven: Philadelphia.Yates, W.R. et al (2015) Anxiety Disorders Treatment & Management. Retrieved from http://emedicine.medscape.com/article/286227-treatment#d8
January 2016: Statins
Statins are medications used to lower low density lipoprotein (LDL) cholesterol (the bad cholesterol), and have modest triglyceride-lowering and high density lipoprotein (HDL) cholesterol raising effects at higher doses. Here are the most common statins you’ll see in the prehospital setting.
November 2015: Your Autoimmune Disease Patient
Often when we respond to sick patients, we're provided with a 'bag of meds'. Here is what you might find in that bag if your patient suffers from an autoimmune condition such as Chrohn's Disease, Rheumatoid Arthritis, etc.
September 2015: Your Diabetic Patient
With diabetic patients making up a significant number of your sick patient calls, do you ever wonder what the difference is between the myriad of Insulin types they are using? Here is a list of the most common types of insulin and their specifics.
Insulin Type - Rapid Acting
Insulin Type - Short Acting
Insulin Type - Intermediate Acting
Insulin Type - Long Acting
Insulin Mixtures - Rapid Acting/Intermediate Acting
Insulin Mixtures - Short Acting/Intermediate Acting
July 2015: Your Arrhythmia Patient
Have you responded to a call recently for a patient with a pre-existing cardiac arrhythmia? You may have found that he/she was taking a number of medications. Below is a list of the common medications you might find that your arrhythmia patient taking.
Beta Blockers (The LOLs)
Calcium Channel Blockers
March 2015: Your Asthma/COPD Patient
Often when we respond to sick patients, we are provided with a "bag of meds". Here is what you might find in that bag if your patient suffers from Asthma or COPD.
Common Respiratory Antibiotics used for COPD Exacerbations
January 2015: Transdermal Patches
Transdermal patches are used to deliver medication via absorption through the skin into the bloodstream. If you come across a patient who has a patch applied that might be the cause of their current presentation, you might want to consider removing the patch. For example, a patient who has a Nitro patch applied and is hypotensive; this patch should be removed. Or how about a suspected overdose patient with a Fentanyl patch on (or perhaps even several patches)? This should also be removed. It is also advisable to remove any transdermal patches from VSAs as part of your differential diagnosis. It is entirely possible that the patch has contributed to the patient’s cardiac arrest.
November 2014: Antihistamines
As you know, histamine is released in response to the presence of an allergen. Reactions can be mild, moderate or severe, with severe cases resulting in anaphylaxis. Antihistamines are used to block histamine receptors and help relieve the symptoms associated with the mild or moderate reaction.
Remember, if you’ve administered Diphenhydramine to a patient for a mild or moderate allergic reaction, do not administer Dimenhydrinate for nausea or vomiting in addition. Administering these medications together could potentially result in an anticholinergic excess causing dry mouth, mild hyperthermia, tachycardia, dilated pupils and CNS changes like confusion, sedation, paradoxical excitation, or even seizure (AskMAC, Nov 22, 2013).
September 2014: Puffers
Puffers, or inhalers, represent a route of administration rather than a class of medication in itself. Several classes of medications may be delivered in this manner and include bronchodilators (short and long-acting β2 adrenergic agonists and anticholinergics), corticosteroids, and newer products that combine the two. These medications are used to treat a variety of respiratory illnesses, predominantly asthma and COPD.
April 2014: Opioids
Opioids are an ancient group of medications that includes natural extracts from the opium poppy, as well as newer semi-synthetic and synthetic derivatives. While most commonly used in the treatment of acute and chronic pain, opioids may also be used to treat diarrhea and cough. The opioid ingestion toxidrome consists of pinpoint pupils, respiratory depression, and coma. The opioid withdrawal syndrome may last more than one week and consists of severe drug craving, anxiety, perspiration, rhinorrhea, anorexia, muscle cramping, nausea, and vomiting.
February 2014: Anticoagulants
Anticoagulants are used primarily in patients with a moderate to high stroke risk, atrial fibrillation, myocardial infarctions, deep vein thrombosis, pulmonary embolism, and mechanical heart valves. They act by targeting clotting factors to increase the amount of time it takes to form blood clots. Bleeding is a common side effect, which can result in mild bruising or epistaxis, but 1-2% will be have more serious bleeding complications (i.e. hemorrhagic stroke, increased risk of intracranial bleeds from trauma, GI bleeds, spontaneous retroperitoneal bleeds etc).
Anticoagulant therapy is a contraindication for the administration of Ketorolac (Toradol) in the Moderate to Severe Pain Medical Directive.
Vitamin K Antagonist
Inhibits clotting factors that depend on Vitamin K for synthesis (Factors II, VII,IX,X). Require monitoring of INR to ensure therapeutic range.
Low Molecular Weight Heparin
As the name implies, these are heparins that are made up of molecules with lower weight than that of unfractionated heparins. These medications bind to Antithrombin, leading to an inhibition of thrombin and factor Xa in the coagulation cascade. These medications are given through subcutaneous injections.
Direct Thrombin Inhibitors
Factor Xa Inhibitors
December 2013: Oral Hypoglycemics / Oral Antihyperglycemics
There are multiple classes of oral hypoglycemic agents (also known as oral antihyperglycemic agents) used in the treatment of type 2 diabetes. These agents act by lowering the glucose level in the blood through the enhancement of insulin production, decreasing glucose production, or increasing the cells ability to uptake glucose.
These are the first line pharmacological treatment for type 2 diabetes. Also used in gestational diabetes and polycystic ovarian syndrome. Causes few adverse effects (mainly GI symptoms upon initiation) and are associated with a very low risk of hypoglycemia. Metformin works by suppressing liver glucose production.
These agents work by stimulating the pancreas to release more insulin. Sulfonylureas block ATP sensitive potassium channels in the Beta-cells of the pancreatic islets. This results in cell depolarization, leading to an influx of calcium into the cell, resulting in increased insulin secretion from the Beta-cells. Patients on sulfonylureas are at higher risk for having hypoglycemic events.
These medications have a quick onset of action and have a short duration of effect. They are structurally different than sulfonylureas and exert their effects via different receptors, but act similarly by regulating ATP dependent potassium channels in pancreatic beta cells, resulting in increased insulin secretion.
This class of medications increases insulin sensitivity by acting on adipose, muscle and liver to increase glucose utilization and decrease glucose production. It is thought they may also improve blood glucose levels by preserving pancreatic Beta-cell function.
These agents are not considered as initial therapy in treatment of type 2 diabetes. They help achieve glucose control through several mechanisms including enhancement of glucose dependent insulin secretion, delayed gastric emptying, regulation of postprandial glucagon and decreased appetite. These agents do not cause hypoglycemia.
These medications inhibit gastrointestinal enzymes (alpha-gluosidases) that convert complex polysaccharide carbohydrates into monosaccharides in a dose dependent fashion. They act by slowing the absorption of glucose from the GI tract.
October 2013: Tricyclic Antidepressants
|Brand Name||Generic/Chemical Name|
|Elavil, Levate, Triptyn||Amitriptyline|
|Pramine, Impril, Tripamine||Imipramine|
Phosphodiesterase inhibitors are a class of drugs that block one or more subtype of the enzyme phosphodiesterase. The most common out of hospital use of this class of medication are those drugs that are PDE5 selective inhibitors. These medications are used to treat erectile dysfunction and are occasionally used in the treatment of pulmonary hypertension.
Phosphodiesterase Inhibitor use within 48 hours is a contraindication for nitroglycerin administration as it can significantly enhance nitroglycerin’s vasodilatory effect and cause profound hypotension.
|Brand Name||Generic/Chemical Name|
|Stendra, Spedra (not approved for use in Canada)||Avanafil|
Here are some of the common NonSteroidal Anti-Inflammatory Drugs (NSAIDs) that you might encounter when treating patients. This is not an exhaustive list, but one that you will hopefully recollect. Recognizing these will come in handy when considering ASA for Cardiac Ischemia or Ibuprofen/Ketorolac for pain. Keep in mind that an allergy or sensitivity to NSAIDs is a contraindication for the administration of ASA, Ibuprofen, and Ketorolac.
|Brand Name||Generic/Chemical Name|
|Anaprox, Naprosyn, Aleve, Vimovo||Naproxen|
|Arthrotec||Diclofenac Sodium with Misoprostol|