# Uncommon Medications Found In Your Drug Box



## NomadicMedic (Feb 16, 2015)

I've got Nesiritide on standing orders for CHF at the new job. It's far down the page, but still there. (Luckily, Lasix and morphine have been removed) I'd not used it before and was reading about it. From all I've seen it's not a huge help in relief of dyspnea and has a risk of significant hypotension. 

Anyone else used it or have experience with it?


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## Ewok Jerky (Feb 16, 2015)

I cant say from experience, but a cursory review of the literature doesn't have much to say about nesiritide for acute chf.  We must be looking at the same trials. One study showed that hospitals have virtually stopped using it since 2005 over fears of renal toxicity.  The ASCEND-HF trial was conducted to assess the safety of the drug and found that while it was not associated with increased mortality, it really wasn't shown to be effective either. The relief of dyspnea at 6 and 24 hours was not significant, neither was the risk of hypotension.

Why don't you like lasix?


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## NomadicMedic (Feb 16, 2015)

I think Lasix is a fine drug, but not one that we really need in the shorter transport prehospital arena. After a work up in the ED if it's found to be appropriate, push it by all means. Lasix has been falling out of favor with medical directors for years, mostly based on the inappropriate dosing. I'll look for the study, but what I seem to recall was almost half of the Lasix given in a study period was inappropraite (pneumonia vs CHF). It looks as though NTG and CPAP is the current standard of care for most prehospital agencies, and that seems to be the best way to manage the majority of CHF cases.


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## Ewok Jerky (Feb 16, 2015)

DEmedic said:


> I think Lasix is a fine drug, but not one that we really need in the shorter transport prehospital arena. After a work up in the ED if it's found to be appropriate, push it by all means. Lasix has been falling out of favor with medical directors for years, mostly based on the inappropriate dosing. I'll look for the study, but what I seem to recall was almost half of the Lasix given in a study period was inappropraite (pneumonia vs CHF). It looks as though NTG and CPAP is the current standard of care for most prehospital agencies, and that seems to be the best way to manage the majority of CHF cases.



Makes sense. I was unaware of dosing problems.  Were they under dosing or overdosing or both?  I agree that NTG and CPAP are standard of care and give patients much more palpable relief than lasix which just makes them want to pee...but I think decompensated CHF patients need the shotgun approach (with in reason of course).  As you know they can crump fast and if you're going to earn your paycheck these are the peeps to do it on (ie. work fast to get everything on your protocol done before arrival at the ED). I never thought about transport times but plenty of emergent transports are still 10+ minutes and if you have 15 or 20 minutes lasix will be absorbed and peaking before you move the Pt off your gurney.  I suppose in a 10 minute transport it would be at the bottom of list after fighting the patient with the CPAP for 9 minutes though.

But I have nothing to say about Nesiritide I would love for someone else to join in


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## MonkeyArrow (Feb 16, 2015)

I know you relocated to Savannah so is this service in GA or SC? Just wondering because reading the GA protocols and scope of practice, nesiritide don't appear to be in the protocol drug formulary but the scope of practice sheet says paramedics can push anything as authorized by the local medical director (except for paralytics, which you need Office of EMS approval for).


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## NomadicMedic (Feb 16, 2015)

It's a GA service. And the protocols are rather different from from the standard state protocols.

...but you're right, we don't have any paralytics or any type of DAI.

I think Nesiritide may be of those odd ball things that just crept in there. For example, I worked for a different service that specified Anzemet as THE anti-emetic. I had never heard of it, but the med control doc preferred it over Zofran. So, we gave Anzemet. 

Curious if anyone else had it in their drug bag.


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## Nova1300 (Feb 17, 2015)

Anzemet in the drug box?!?

What a complete waste of money and misuse of that drug.  

Almost as wasteful and expensive as prehospital Natrecor.  

Ridiculous.


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## NomadicMedic (Feb 17, 2015)

Sorry I don't have time at the moment to get into this one deeper, but I just did a quick look on my phone. Seems the end effect of Anzemet vs Zofran is similar, with Anzemet doing a slightly better job of controlling post op nausea and a study facility found a cost savings in using Anzemet. Of course, these are older studies, but this was an EMS protocol from a few years back.

http://www.ncbi.nlm.nih.gov/m/pubmed/10825320/?i=3&from=/15673860/related

http://www.ncbi.nlm.nih.gov/m/pubmed/15673860/?i=2&from=/10825320/related

That doesn't look like a "complete waste of money and misuse of the drug".











Nova1300 said:


> Anzemet in the drug box?!?
> 
> What a complete waste of money and misuse of that drug.
> 
> ...


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## Nova1300 (Feb 17, 2015)

Remind me which of your patients have post-op nausea vomiting?


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## NomadicMedic (Feb 17, 2015)

Remind me why post op N/V any different from NON post op N/V?


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## Nova1300 (Feb 17, 2015)

Very different.

Nausea can be mechanical, originating in the hollow viscera, or it can originate from several different parts of the brain, namely CN 8 or the chemosensitive trigger zone.  Along with a few other places.


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## NomadicMedic (Feb 17, 2015)

So, Zofran, which is a serotonin receptor antagonist and noted to be effective in relieving chemoreceptor triggered nausea is okay to use in prehospital arena, but Anzemet, which is a serotonin receptor antagonist and noted to effective in releiving chemoreceptor triggered nausea is *not* okay. 

Both of these drugs are used as antiemetic agents following surgery, chemo, radiation and both are noted to be used as an antiemetic in cases of gastroenteritis. 

I just want to make sure I've got that right and I'm not missing a major part of your "misuse of the drug" statement.


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## Carlos Danger (Feb 17, 2015)

I've never used dolasetron and honestly don't know much about it or how it differs from ondansetron. I would just point out that just because they are both 5ht3 antagonists doesn't mean they don't have significantly different effects (think epi vs norepi, or meperidine vs nalbuphine vs fentanyl) or affect different subtypes of patients differently (neuropathic vs nociceptive pain, for instance).

I've never used nesitiride, either. Or heard of it being used prehospital. Interesting mechanism of action with that one.


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## Nova1300 (Feb 18, 2015)

DEmedic said:


> So, Zofran, which is a serotonin receptor antagonist and noted to be effective in relieving chemoreceptor triggered nausea is okay to use in prehospital arena, but Anzemet, which is a serotonin receptor antagonist and noted to effective in releiving chemoreceptor triggered nausea is *not* okay.
> 
> Both of these drugs are used as antiemetic agents following surgery, chemo, radiation and both are noted to be used as an antiemetic in cases of gastroenteritis.
> 
> I just want to make sure I've got that right and I'm not missing a major part of your "misuse of the drug" statement.




Nope.  I don't really like 5HT3 blockers prehospital generally. It's fine, use them.  It may work on some.  But they were deloped to treat nausea and vomiting in a specific part of the nausea pathways, triggered by emetogenic chemotherapy.  They later got an indication for prevention of PONV which also is believed to be associated with the chemosensitive trigger zone.  These are the only two indications for these drugs.  Other uses are off-label and I believe unproven.  And to be honest, anecdotally, I don't find zofran to be very effective at the prevention of PONV in those at highest risk (patients with known history of PONV). These patients usually get a cocktail of drugs with different mechanisms.

Paramedics are perfectly capable of dosing antihistamines or phenothiazines (drugs with long, established history of efficacy in treating most forms of N/V) incrementally so as to avoid sedation.  They are also both cheap and plentiful. 


Admittedly, we didn't carry anti-emetics where I practiced. Maybe 5HT3 blockers work for most patients out in the field, I just don't know. But, I can tell you that when I use it off-label in the hospital, I see a lot of non-responders.


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## Handsome Robb (Feb 18, 2015)

We carry zofran and phenergan. Unfortunately we can't use phenergan unless they're allergic to zofran.

In my experience zofran has worked well in patients who are nauseous but are not vomiting. I've not had success using it as a "rescue drug" in actively vomiting patients.

Zofran is widely used in the prehospital environment. If it was not effective why would a multitude of agencies continue to use it? While it my be potentially viewed as off-label since we aren't administering it for post chemo/radiation therapy patients or post-operative patients the majority of the time it is still indicated for nausea. Furthermore it is consistently used in the ER for the same indication of N/V as well as prophylactically with analgesia with good effect.

While it may be "off label" use what is the harm as it is a relatively benign drug. Yes there is a black box warning, however that warning is for high (32mg) IV doses. In EMS we treat symptoms the majority of the time so why not treat someone who is nauseous if we have the capabilities?

In an attempt to keep this thread semi-on topic I don't know a lot about nesiritide but on the topic of lasix it's not a good medication in the acute setting due to the fact that even though exacerbated CHF patients may seem fluid overloaded due to the peripheral and pulmonary edema they are actually volume depleted hence the indication for cautious fluid challenges. Lasix is not indicated in volume depleted patients.


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## NomadicMedic (Feb 18, 2015)

Agreed. I apologize for getting the thread off topic, but these discussions are what makes this forum so interesting.

I've not had much success with Zofran (or Anzemet) in actively vomiting patients, and in the case of mechanical vomiting, that's not something I particularly want to stop. In the instance of non responders to Zofran, I've got Phenergan, Benadryl and Halperidol that I can use as a rescue drug. As an aside, I found that 12.5 to 25mg of Anzemet  was a VERY effective prehospital antiemetic and while I only used it for a year, I gave it frequently and always had good success. As I mentioned , I no longer work forthe  service that used Anzemet and I believe that they no longer carry it. (New medical director, new protocols, new drug.)

I found that I frequently needed to escalate the Zofran dose to 8mg to get on top of a patients nausea, and luckily the DE protocols specified 8mg as the standard adult dose.

Anyway, back to Nesiritide, I really can't find any good reason to pull it out of the box and it's doubtful that I'll ever administer it.


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## triemal04 (Feb 18, 2015)

Handsome Robb said:


> Zofran is widely used in the prehospital environment. If it was not effective why would a multitude of agencies continue to use it?


Because since the patent ran out and generic forms became available it is quite cheap, and doesn't have any of the side-effects associated with other anti-emetics.  

I carried it while it was still only available as Zofran (no generic), but we were one of the few as it was...ehm...expensive.  After the patent ran out in '06 or '07 and it became available as Ondansetron, that's when it really became popular.  It was also sometime around then that someone (a nurse I think) lost a lawsuit related to improper admin of phenergan...that probably played a part too.


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## Nova1300 (Feb 18, 2015)

Handsome Robb said:


> We carry zofran and phenergan. Unfortunately we can't use phenergan unless they're allergic to zofran.
> 
> In my experience zofran has worked well in patients who are nauseous but are not vomiting. I've not had success using it as a "rescue drug" in actively vomiting patients.
> 
> ...



Careful with that word.  5HT3 blockers are not indicated for either of the conditions you mention unless they are due to highly emetogenic chemotherapy or PONV.  You use them, but off-label.  And it's an important distinction to make.   

If you want to give zofran to everybody the minute they hit the stretcher, that's fine.  It's your paycheck (or taxes)paying for these drugs.  

But you are comparing a drug which costs more and is a poor choice as a broad-spectrum antiemetic to a class of drugs that have an established history of efficacy as general antiemetics, are cheaper, easier to replace in times of shortage, can truly be titrated to effect, provide some degree of anxiolysis, and suppresses the CN8 nausea from going backward down the road, which only exacerbates the original cause of the nausea.  


If 5HT3 is your drug of preference, then so be it.  You won't hurt anyone.  But, I'm gonna bet you are far more likely to have puke on your uniform. 


Putting Natrecor in an EMS drug box when a good percentage of the critical care community is still unconvinced it has any utility whatsoever, seems a bit absurd. Is there some collection of litterature of which I'm just unaware?  Where did this idea even come from? 

I have similar feelings on lasix.  Giving diuretics to a heart failure patient prior to treating the failing heart results in a volume-depleted patient with wet lungs.  And that diuresis tends to drag patients all over the starling curve.


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## NomadicMedic (Feb 18, 2015)

I think we're on the same page with the Nesirtiride. I can't find anything that shows it's really of any prehospital value. 

But I think you're missing the boat on the prehospital use of the 5HT3 drugs.


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## polisciaggie (Feb 18, 2015)

We carry hydralazine for hypertensive patients that are bradycardic. Never used it though.


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## chaz90 (Feb 18, 2015)

My old service in Colorado carried Zyprexa.


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## STXmedic (Feb 19, 2015)

We've got Zyprexa here.


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## Handsome Robb (Feb 19, 2015)

Nova1300 said:


> Careful with that word.  5HT3 blockers are not indicated for either of the conditions you mention unless they are due to highly emetogenic chemotherapy or PONV.  You use them, but off-label.  And it's an important distinction to make.
> 
> If you want to give zofran to everybody the minute they hit the stretcher, that's fine.  It's your paycheck (or taxes)paying for these drugs.
> 
> ...



It's not that 5HT3 blockers are my drug of preference, it's my only option. The only way I can administer phenergan is if the patient is allergic to zofran so unfortunately my hands are tied. I will say that I find it offensive that you'd imply I give zofran to "everybody the minute they hit the stretcher". I'm not sure how you came to that conclusion after I clearly stated what my protocols allow. I'm far from a protocol monkey but at the end of the day I have to follow them and our OLMD physicians aren't big on giving us orders for phenergan over zofran no matter the case you present them.

If there are better drugs which are more effective and are cheaper then why aren't we using them? Why is ondansetron one of the most widely used anti-emetic medications out there? I agree that phenergan is more effective, I'm not arguing that point, but my question still stands...why is zofran one of if not the most common anti-emetic medication administered in the prehospital setting when there are better medications that are apparently cheaper out there?

Also, you are correct, I did more reading on zofran today and have not found anything listing an indication as nausea other than what you noted.


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## triemal04 (Feb 19, 2015)

Handsome Robb said:


> why is zofran one of if not the most common anti-emetic medication administered in the prehospital setting when there are better medications that are apparently cheaper out there?


Because since the patent ran out and generic forms became available it is quite cheap, and doesn't have any of the side-effects associated with other anti-emetics. 

This, this and only this.  You have a cheap, fairly effective drug that can be given by ANY route without any of the side effects of other anti-emetics.  Very simple and non-thought provoking.

You really shouldn't hold up medications being give prehospitally as a reason for that med being "good" either.  With the state of EMS and the overall addiction to fads and shiney object syndrome...not a good idea.


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## TransportJockey (Feb 19, 2015)

I'd say my 8mg vials of atropine. Three of them.


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## NomadicMedic (Feb 19, 2015)

Who still has amyl nitrate?


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## TransportJockey (Feb 19, 2015)

DEmedic said:


> Who still has amyl nitrate?


I did in Pecos.


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## Nova1300 (Feb 19, 2015)

Handsome Robb said:


> It's not that 5HT3 blockers are my drug of preference, it's my only option. The only way I can administer phenergan is if the patient is allergic to zofran so unfortunately my hands are tied. I will say that I find it offensive that you'd imply I give zofran to "everybody the minute they hit the stretcher". I'm not sure how you came to that conclusion after I clearly stated what my protocols allow. I'm far from a protocol monkey but at the end of the day I have to follow them and our OLMD physicians aren't big on giving us orders for phenergan over zofran no matter the case you present them.
> 
> If there are better drugs which are more effective and are cheaper then why aren't we using them? Why is ondansetron one of the most widely used anti-emetic medications out there? I agree that phenergan is more effective, I'm not arguing that point, but my question still stands...why is zofran one of if not the most common anti-emetic medication administered in the prehospital setting when there are better medications that are apparently cheaper out there?
> 
> Also, you are correct, I did more reading on zofran today and have not found anything listing an indication as nausea other than what you noted.




Whoa, sunshine.  My implication was never meant to be that you are pushing drugs needlessly.  The point of my statement was yes, the medication is generally safe and your could give it out like candy if you wished.  Not you personally.  

The reason I think it is used is because ER folks have this irrational fear that medics giving the other classes of anti-emetics are gonna result in having to intubate everyone as they roll through the door.  Which is ridiculous.  

That's my theory, at least.


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## MonkeyArrow (Feb 19, 2015)

TransportJockey said:


> I'd say my 8mg vials of atropine. Three of them.


Is it to be used for organophosphate poisoning?


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## NomadicMedic (Feb 19, 2015)

MonkeyArrow said:


> Is it to be used for organophosphate poisoning?



Or someone who's reeeeeeeeeeeeely bradycardic.


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## DesertMedic66 (Feb 19, 2015)

TransportJockey said:


> I'd say my 8mg vials of atropine. Three of them.


We only carry 2 of those.


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## Chewy20 (Feb 22, 2015)

TransportJockey said:


> I'd say my 8mg vials of atropine. Three of them.


 
We have a bunch of atropine as well. Only have seen it pushed once since I have been here for a lady with a HR in the 20's.


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## Carlos Danger (Feb 22, 2015)

Chewy20 said:


> We have a bunch of atropine as well. Only have seen it pushed once since I have been here for a lady with a HR in the 20's.



My very first call as a cleared paramedic was for a guy in 3rd degree AV block with PVC's and a pulse rate in the 20's. IIRC, I gave him several mg of atropine with no or little effect, and ended up pacing him.


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## RocketMedic (Feb 22, 2015)

I'd reckon that's more for "super industrial death chemical day" than cardiac lol...


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## NomadicMedic (Feb 22, 2015)

Digging through the med box today, we still have Demerol. 

No fentanyl, but all the Demerol you can stand.  

Oh, Romazicon too.


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## TransportJockey (Feb 22, 2015)

Lol yep. I didn't even carry that much when I was on the ground in really rural areas. Not sure why I carry it now though.


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## NomadicMedic (Feb 22, 2015)

Two beta blockers... But no cardizem.


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## Chewy20 (Feb 22, 2015)

Remi said:


> My very first call as a cleared paramedic was for a guy in 3rd degree AV block with PVC's and a pulse rate in the 20's. IIRC, I gave him several mg of atropine with no or little effect, and ended up pacing him.


 
We got her rate to start bouncing around in the 40-50s if I remember correctly. Pacing was the next step, but she was concious and alert the whole time somehow so luckily we didnt need to. No radial pulses, unobtainable manual BP on arrival. Think the ER doc said it turned out to be hyperkalemia.


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## Carlos Danger (Feb 22, 2015)

DEmedic said:


> No fentanyl, but all the Demerol you can stand.



Holy crap that's insane.


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## medicdan (Feb 22, 2015)

DEmedic said:


> Two beta blockers... But no cardizem.


That's whack.


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## RocketMedic (Feb 23, 2015)

Demerol is pretty good stuff for most folks. I like fent, but would absolutely love more options. Acadian's narcs are often inadequate.


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## Carlos Danger (Feb 23, 2015)

Meperidine is not only a weaker analgesic than fentanyl or morphine, but it's also much dirtier. Lots of side effects. Ideally shouldn't be used in older patients or anyone on an SSRI or MAOI, which adds up to what, at least 50% of the population?

No one uses it for anything anymore, because the available alternatives are simply better. I can't envision any scenario where I would choose meperidine over the alternatives.


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## Brandon O (Feb 23, 2015)

There are still patients/occasions where it seems to be the most effective drug... although that could certainly be hokum.


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## Carlos Danger (Feb 23, 2015)

Brandon O said:


> There are still patients/occasions where it seems to be the most effective drug... although that could certainly be hokum.



They used to say that it was less likely to cause biliary spasm than morphine, but that was debunked.

Supposedly it is more effective than other opioids for non-nociceptive pain, but because of its side effect profile, it's still not widely used for that. There are other drugs that are better options.


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## johnrsemt (Feb 23, 2015)

Normal med box:  Pitocin, Romazicon, AATNA's (New style Mark I Kits), Phenergan and Zofran.
Narcs:  Fentanyl, Morphine, Versed and Valium  and 10mg Valium Auto Injectors


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## Brandon O (Feb 23, 2015)

... Pitocin? What for?


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## TransportJockey (Feb 23, 2015)

Brandon O said:


> ... Pitocin? What for?


Most agencies I've worked for have carried pit... I didn't realize it was uncommon.


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## Brandon O (Feb 23, 2015)

For postpartum bleeding or what?


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## TransportJockey (Feb 23, 2015)

Brandon O said:


> For postpartum bleeding or what?


Yep uncontrolled hemorrhage especially in long transport settings.


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## Brandon O (Feb 23, 2015)

That's cool.


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