1. Introduction to Emergency Medical Care 1
Advance Preparation
Invite a hospital pharmacist to class.
Prepare examples of medications and medication fact sheets.
Prepare medication administration simulators and manikins.
Prepare IV fluids and administration sets.
Prepare medication resources

2. OBJECTIVES
18.1 Define key terms introduced in this chapter. Slides 13–20, 26, List the drugs in your scope of practice. Slides 13–22
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3. OBJECTIVES
18.3 For each medication you may administer or assist a patient in self-administering, describe the following: generic and common trade names; indication(s); contraindications; side effects and untoward effects; form(s); route(s) of administration. Slides 25–26, 32–33
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4. OBJECTIVES
18.4 Follow principles of medication administration safety, including the five rights of medication administration. Slides 27– Discuss the importance of looking up medications and requesting information from medical direction when needed. Slides 26–28, 37
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5. OBJECTIVES
18.6 Identify the type of medical direction (on-line or off- line) required to administer each medication in the scope of practice. Slide Describe the characteristics of the oral, sublingual, inhaled, intravenous, intramuscular, subcutaneous, and endotracheal routes of administration. Slides 32–33
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6. OBJECTIVES
18.8 Identify special considerations in medication administration related to patients’ ages and weights. Slide Explain the importance of accurate documentation of drug administration and patient reassessment following drug administration. Slide 35
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7. OBJECTIVES
18.10 Discuss the importance of having readily available references to identify drugs commonly taken by patients. Slide Discuss the steps an EMT may take in assisting with IV therapy. Slides 41–49

8. MULTIMEDIA Slide 23 Oral Glucose Administration Video
This video appears later in the presentation; you may want to preview it prior to class to ensure it loads and plays properly. Click on the link above in slideshow view to go directly to the slide.

9. Which medications may be carried by the EMT
Which medications the EMT may help administer to patients
What to consider when administering any medication
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10. The role of medical direction in medication administration
How the EMT may assist in IV therapy

11. Topics Medications EMTs Can Administer
General Information About Medications
Medications Patients Often Take
Assisting in IV Therapy
Planning Your Time: Plan 100 minutes for this chapter.
Medications EMTs Can Administer (30 minutes)
General Information About Medications (30 minutes)
Medications Patients Often Take (20 minutes)
Assisting in IV Therapy (20 minutes)
Note: The total teaching time recommended is only a guideline.

12. Medications EMTs Can Administer
Teaching Time: 30 minutes
Teaching Tips: Pathophysiology plays an important role in this discussion. EMTs should know why they are administering a medication. Have examples of medications on hand. Demonstrate common packaging and medication labels. Use medication resources such as drug manuals and online pharmacology sites. Discuss how students might use such resources as well. Invite a hospital pharmacist to discuss these medications.

13. Aspirin
Point to Emphasize: Aspirin is given to suspected cardiac chest pain patients to reduce the blood’s ability to clot.
Talking Points: There are six medications that EMTs can administer in the field. In addition, many systems allow the administration of activated charcoal. Always consult local protocol to confirm which medications you are allowed to carry and administer. Aspirin is indicated for patients with chest pain of a suspected cardiac origin. The action of this drug is reducing the blood’s ability to clot. The rationale for chewable aspirin on the ambulance is that most ambulances don’t carry water. Aspirin is contraindicated in patients who have allergies and gastrointestinal bleeding.
Knowledge Application: Have students work in small groups. Assign each group a medication and a drug resource. Have groups research and discuss important pharmacology and administration information.

14. Oral Glucose
Point to Emphasize: Oral glucose is commonly administered to reverse life-threatening low blood sugar.
Talking Points: The brain is very sensitive to low levels of sugar. Oral glucose is used on conscious patients with a history of diabetes and altered mental status. Glucose is supplied in squeezable tubes, so it can be distributed to a tongue depressor and placed between the cheek and gum. Total dose is 25 grams. (This is also discussed in Chapter 21.)
Knowledge Application: Have students work in small groups. Assign each group a disease or similar pathology. Ask group members to describe how a medication would help treat the particular disorder.

15. Oxygen
Point to Emphasize: Supplemental oxygen is valuable in treating hypoxia.
Talking Points: Oxygen is the most commonly administered drug by EMS providers. It is administered to medical or trauma patients who may be in danger of hypoxia.

16. Activated Charcoal
Talking Points: Though it is not technically one of the six common medications carried on the ambulance, we will discuss its use here. It is sometimes used in poisoning cases. It is a powder prepared from charred wood, and is premixed with water. Its action is to absorb some poisons to prevent absorption by the body. A total adult dose is 25 grams. (See Chapter 23, Poisoning and Overdose for administration.) Side effects are vomiting and tarry stool.

17. Bronchodilator Inhaler
Point to Emphasize: EMTs frequently can assist patients with inhaled respiratory medications, sublingual nitroglycerine, and auto-injected epinephrine.
Talking Points: Examples of these medications include albuterol (Ventolin, Proventil, Volmax) and levalbuterol (Xopenex).
Knowledge Application: Discuss a patient’s medication list. Have students use drug resources to discuss why these medications may have been prescribed.

18. Prescribed Bronchodilator Inhalers
Used in patients with asthma, emphysema, and chronic bronchitis
Enlarges constricted breathing tubes
Side effects: increased heart rate, patient jitteriness
Talking Points: Be sure to determine that the inhaler is actually the patient’s and does not belong to a family member or bystander. Always comply with the protocols of your EMS system.

19. Nitroglycerin
Talking Points: This is the spray, but it is also available as a pill.
Knowledge Application: Discuss local protocols for medication administration. What are the rules in your area?

20. Prescribed Nitroglycerin
Taken by patients with history of chest pain of cardiac origin
Helps dilate coronary vessels
Contraindications: low blood pressure or taking medications for erectile dysfunction (Viagra, Levitra, Cialis, or similar)
Vasodilator
Side effect: dropping blood pressure
Talking Points: Nitroglycerin is often called just “nitro.” If there is a drop in blood pressure, you may need to lay the patient flat as you recontact medical direction for advice. Always comply with the protocols of your EMS system. (More information on nitroglycerin is found in Chapter 20.)
Critical Thinking: What role does documentation play in the administration of medications? Why might it be important to document each administration carefully?

21. Epinephrine Auto-Injector
Talking Points: Epi-Pen® is the trade name of a commonly carried epinephrine auto-injector. Twinject® is the trade name of an auto-injector that contains two doses of epinephrine.
Discussion Topics: Describe the six medications commonly administered by an EMT. Describe three patient medications with which an EMT may assist. Describe at least two categories of commonly prescribed patient medications.
Epinephrine Auto-Injector

22. Prescribed Epinephrine Auto-Injectors
Prescribed and used for patients with severe allergic reactions classified as anaphylaxis
Vasoconstrictor; relaxes smooth muscles and airway passages
Side effects: increased heart rate and blood pressure
Talking Points: Patient could be highly allergic to something like shellfish, penicillin, or a bee sting. Anaphylaxis is a life-threatening allergic reaction affecting the patient’s airway and circulation. Severe allergic reactions may reach life-threatening stage in a very short time, so epinephrine must be administered quickly. You may need to seek permission from medical direction by phone or radio, or there may be a standing medical order that permits you to assist a patient with an epinephrine auto-injector. Always comply with the protocols of your EMS system.
Class Activity: After your discussion on drug resources, assign medication research. Have students research and discuss the pathophysiology (mechanism of action) of the commonly administered medications.

23. Oral Glucose Administration Video
Video Clip
Oral Glucose Administration
What are the indications for the administration of oral glucose?
Where should you administer the glucose?
What medications might a patient who needs oral glucose take?
Explain how to administer oral glucose.
Click here to view a video on the subject of oral glucose administration.
Back to Directory

24. General Information About Medications
Teaching Time: 30 minutes
Teaching Tips: Demonstrate medication listings using drug resources. Discuss how an EMT can use these resources. Invite a pharmacist to discuss medication administration. Have plenty of medication examples on hand. Demonstrate different forms and administration routes. Make the “five rights” an ongoing lesson. Any time a student wishes to administer a medication in practice sessions, make him review these points.

25. Drug Names Each drug is listed by a generic name
Each drug has at least three names
Chemical name
Generic name
Brand name (one or more trade names given to the drug by manufacturers)
Point to Emphasize: Each drug has at least three names: the chemical name (B-(3, 4 dihydroxyphenyl)-a-methylaminoethanol), the generic name (epinephrine), and one or more trade (brand) names (Epi-Pen®).
Discussion Topic: Discuss the three names of a medication. What are the origin and significance of each name?

26. What You Need to Know When Giving a Medication
Indications
Contraindications
Side effects
Untoward effects
Point to Emphasize: Before administering a medication, an EMT must understand that drug’s indications, contraindications, and side effects.
Talking Points: Indications are specific signs, symptoms, or circumstances under which it is appropriate to administer the drug to a patient. Contraindications are specific signs, symptoms, or circumstances under which it is not appropriate, and may be harmful, to administer the drug to a patient. Side effects are any actions of a drug other than the desired action. Untoward effects are effects that are not only unexpected, but also potentially harmful to the patient.
Discussion Topic: Define indication, contraindication, and side effect.
Class Activity: Ask each student to research and list the indications, contraindications, and side effects of the six medications that EMTs commonly administer.

27. Medication Safety and Clinical Judgment
Administering or assisting with medications is a serious responsibility
Know the medication
Use good judgment
Talking Points: Once the medication is administered, you cannot take it back. Focus, clear thinking, and good judgment all help assure proper and safe treatment.

28. Medication Authorization
Off-line medical direction
Do not speak to physician
Use standing orders
On-line medical direction
Speak directly to physician
Listen to order; then repeat order back
Ask for clarification if necessary
Talking Points: Off-line medical direction uses “standing orders”; that is, orders written down in the form of protocols. Providers learn these protocols and administer medications guided by the specific circumstances and conditions previously outlined in their rules and regulations. On-line medical direction involves speaking directly to a physician (or designee) to obtain verbal permission to administer a medication. Verbal confirmation is required. Be diligent to ensure you have heard and correctly understand the instructions. Use the “echo technique”: listen to the order and then repeat the order back. The physician then gives you verbal confirmation that what you have heard is correct. This significantly reduces medication errors. If you are confused or have a question, speak up. Asking for clarification while on line always is appropriate.

29. The Five Rights of Medications
Point to Emphasize: EMTs must have appropriate authorization to give a drug and always must follow the “five rights” of medication administration.

30. The Five Rights Do I have the right patient?
Is it the right time to administer this medication?
Is this the right medication?
Is this the right dose?
Am I giving this medication by the right route of administration?
Talking Points: Use these questions to answer the “five rights.” Does this medication belong to the patient? Is this the same patient medical direction approved a medication order for? Have I made the right decision to administer the medication based on what I am seeing? Is it appropriate under these circumstances to give this particular medication? Did I pick up the right bottle? Am I sure this is the correct medication? Have I double checked? Am I sure I am giving the correct amount?
Discussion Topic: What are the “five rights” of medication administration?
Knowledge Application: Assign medication administration scenarios to small groups. Ask group members to discuss how they would administer the medication. Include the “five rights.”
Critical Thinking: Occasionally trade names of medications are similar. How might this similarity be dangerous in medication administration? What steps might an EMT take to avoid this danger?

31. Think About It
What would be the potential risk to the patient if each of the “five rights” were not checked prior to administration?
Talking Points: Checking each of the “five rights” ensures that the correct dosage of the correct medication is given to the correct person at the correct time through the right route. If any of these are not checked the result could be a worsening of the patient’s condition at best, with the possibility of more serious consequences.

32. Routes of Administration
Oral (swallowed)
Sublingual (dissolved under tongue)
Inhaled (breathed into lungs), usually as tiny aerosol particles such as from an inhaler or as a gas such as oxygen
Intravenous (injected into vein)
Point to Emphasize: Medications can be found in a variety of forms and can be administered through a variety of routes.
continued

33. Routes of Administration
Intramuscular (injected into muscle)
Subcutaneous (injected under skin)
Intraosseous (injected into bone marrow cavity)
Endotracheal (sprayed directly into tube inserted into trachea)
Discussion Topic: Describe three medication administration routes.

34. Age- and Weight-Related Considerations
Pharmacodynamics
Study of effects of medications on body
What effect will medication have on this patient?
Patient-specific factors change how medication works
Talking Points: It is important to consider pharmacodynamics any time you administer a medication. What effect will this medication have? How will it effect my patient? Remember that patient-specific factors can change how a medication will work.

35. Reassessment and Documentation
After administering medication, reassess patient
Clearly document medications administered
Point to Emphasize: Reassessment and documentation are crucial following any medication administration.
Talking Points: Reassessment should occur immediately and be frequently repeated, especially with medications that take time to take effect. Good documentation must include the name of the medication (spelled correctly), the dose of the medication, the specific route by which it was administered (“injected into the right upper thigh”), the time of administration, and any effects you noted. Remember that the hospital will continue to give the patient medications and must know what has already been administered in order to carry out a safe treatment plan.
Knowledge Application: Follow up any medication administration scenarios with a reassessment and documentation project. (Consider a homework assignment.)

36. Medications Patients Often Take
Teaching Time: 20 minutes
Teaching Tips: This lesson is more about students’ ability to use resources than it is about medications. Give students the tools to find information on their own. Relate this lesson to patient assessment. Discuss how patient medications relate to establishing a thorough patient history. Have a variety of resources on hand. Try to demonstrate a variety of the options available.

37. Medications Patients Often Take
Points to Emphasize: Patient medications can indicate underlying health problems. Use drug resources to identify unknown patient medications.
Talking Points: It is impossible to know everything about every medication that is on the market. For example, AdvairTM is a drug prescribed for chronic respiratory conditions, but it should not be used to reverse an acute asthma attack and alleviate breathing difficulty. There are many resources available such as field guides and the PDR that can be kept on the ambulance for use en route to the hospital. Many of these are in digital forms that can be downloaded to cell phones and PDAs.
Discussion Topics: Explain how knowledge of the patient’s medications can help identify underlying health problems. Discuss how you might identify the purpose of a prescribed medication if you did not recognize it immediately.
Class Activity: After your discussion on drug resources, assign medication research. Have students research and discuss the pathophysiology (mechanism of action) of the commonly administered medications.

38. Talking Points: Reassessment of vital signs and documentation of patient response to each drug is of vital importance after any medication intervention.
Discussion Topic: Describe at least two categories of commonly prescribed medications. Why might each category be prescribed?
Knowledge Application: Present patient medication lists. Using drug resources, ask students to hypothesize what the patient’s medical history might include. Make two lists: common medications and categories of prescribed medications. Ask students to match medications to the appropriate categories.
Critical Thinking: Could a prescribed medication that your patient is taking affect a medication that you intend to administer? How might you make this determination?

39. Herbal Agents and Basic Uses
Point to Emphasize: Understanding basic categories of common medications and herbal supplements can be helpful in assessing and treating a patient.
Knowledge Application: List common herbal supplements. Ask students to discuss the potential effects of each one.

40. Assisting in IV Therapy
Teaching Time: 30 minutes
Teaching Tips: Have IV administration sets on hand for demonstration. This is a “hands on” lesson. Use a manikin arm or other simulator to demonstrate IV administration. Use graphics and drawings to assist students in learning the various IV administration set components.

41. Ways of Administering IV Fluids
Heparin (saline) lock
Catheter placed into vein
Cap (lock) placed over end of catheter
Lock has port for administering medications
Traditional IV bag
Hangs above patient
Constantly flows fluids and medications into patient
Points to Emphasize: Intravenous access is accomplished to provide a direct route for medication administration into the vein. Heparin/saline locks and constant infusion are two common methods of intravenous access.

42. IV Fluid Administration Set
Clear plastic tubing connecting fluid bag to needle or catheter
Three important parts
Drip chamber
Flow regulator
Drug or needle port
Extension set (extra tubing)
Points to Emphasize: An EMT should understand the components and assembly of commonly used intravenous administration sets.
Discussion Topic: Describe the common components of an intravenous administration set. What is the role of each component?
Knowledge Application: Using a drawing, have students label the common components of an intravenous administration set.
Critical Thinking: What are the local rules and regulations regarding IV management in your area?

43. Setting Up an IV Fluid Administration Set
Talking Points: Make sure that the fluid bag has no leaks; reconfirm this by squeezing it. Look at the solution to make sure it is clear, and check the expiration date.
Setting Up an IV Fluid Administration Set
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44. Setting Up an IV Fluid Administration Set
Talking Points: Orient students to the various types of drip sets and the components of the sets. Also stress sterile technique in not letting the ends of the set touch the ground.
Knowledge Application: Have students work in small groups. Provide each group with an IV administration set and ask group members to assemble it.
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45. Setting Up an IV Fluid Administration Set
Talking Points: Close the flow regulator all the way. In doing so, you must roll the stop cock in the direction away from the fluid bag.
Setting Up an IV Fluid Administration Set
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46. Setting Up an IV Fluid Administration Set
Talking Points: Very carefully insert the spiked end of the tubing into the bag with a twist, making sure not to allow the ends of the tubing to touch the ground. (If they do, the set will be contaminated and must be disposed.) Introducing germs directly into the patient’s bloodstream can be fatal.
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47. Setting Up an IV Fluid Administration Set
Talking Points: Hold the fluid bag higher than the drip chamber. Squeeze the drip chamber once or twice. Fill the chamber to the marker line (approximately one-third to one-half full).
continued

48. Setting Up an IV Fluid Administration Set
Talking Points: Open the flow regulator by rolling the stopcock toward the fluid bag and flush the line (removes all of the air from the tubing). Maintain sterility (in the event you need to loosen the cap at the end of the tubing). Once the line is flushed, turn off the flow.
Discussion Topic: Describe the steps involved in assembling an IV administration set.
Class Activity: Invite advanced providers to class. Distribute providers among groups of students and have them prepare IV administration sets. Allow the providers to share their insights and tips.

49. Maintaining an IV Troubleshoot flow problems Adjust flow rate properly
Constricting bands left in place by mistake
Flow regulator left closed
Clamp closed on tubing
Tubing kinked
Line pinched under backboard (trauma)
Adjust flow rate properly
Monitor IV sites for infiltration
Point to Emphasize: IV maintenance may require an EMT to troubleshoot common problems with continuing flow.
Talking Points: If you are maintaining an IV, you must look for and correct these problems and others. Recognize that the components of the IV may be blocked from view by clothing, splint, and so on. Some IVs flow only when IV site is in a certain position; repositioning the patient’s arm or splinting it may remedy this. Overfilling of the drip chamber may be solved by shutting down the IV, inverting the bag, and squeezing the drip chamber to pump fluid back into the bag. Know KVO rates: usually 30 drops per minute for micro drip and 10 drops per minute for macro drip. Watch out for runaway flows. Watch IV sites for infiltration characteristics such as swelling and pain. An infiltration that goes unnoticed can be very dangerous when combined with drug administration such as 50% Dextrose and necrosis of the skin.
Discussion Topic: Discuss the common problems that might cause an IV to stop running. What steps can an EMT take to troubleshoot these problems?
Knowledge Application: Present scenarios in which an IV is no longer running. Ask the class to work through troubleshooting practices. Discuss.

50. Chapter Review

51. Chapter Review
Aspirin, oral glucose, charcoal, and oxygen are medications carried on the ambulance that the EMT may administer to a patient under specific conditions.
Inhalers, nitroglycerin, and epinephrine in auto-injectors are medications that, if prescribed, the EMT may assist the patient in taking
continued

52. Chapter Review
You may need to have permission from medical direction to administer or assist the patient with a medication. Follow local protocols.
continued

53. Chapter Review
Find out what medications a patient is taking when you take the SAMPLE. Your main purpose in finding this out is to report this information to your Medical Director or hospital personnel.

54. Remember
EMTs administer aspirin, oral glucose, activated charcoal, and oxygen as part of patient care.
EMTs may assist with inhaled respiratory medications, nitroglycerine, and epinephrine auto-injectors.
continued

55. Remember
EMTs should understand the names, indications, contraindications, and side effects of medications that they intend to administer.
EMTs must have appropriate authorization to give a drug and always must follow the “five rights” of medication administration.
continued

56. Remember
Reassessment and documentation are important elements of medication administration.

57. Questions to Consider Should I administer a medication?
How can I get more information about a drug?
What are the necessary steps that must occur after medication administration?
Talking Points: EMTs must look to local protocol and examine patient condition before giving any drug. In addition, EMTs must apply the “five rights” of medication administration.
EMTs should know how to access medication resources to gather additional information regarding an encountered medication.
EMTs must remember that reassessment and documentation are critical elements that must follow any intervention.

58. Critical Thinking
A patient is complaining of chest pain. Here’s some nitroglycerin,” says a family member. “Give him that.” What do you do?
Talking Points: The essential point is to follow the “five rights” of administering medications. These will lead you to acting appropriately in each situation.

59. Please visit Resource Central on www. bradybooks
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