07 EMT Medications

Medication safety framework

Medication use is a patient-safety process rather than simply the act of giving a drug. The EMT should move through a consistent sequence:

1. Perform the primary assessment and correct immediate life threats such as airway obstruction, inadequate breathing, severe bleeding, or shock.

2. Identify the patient’s likely problem and determine whether the medication is indicated.

3. Confirm authorization through local protocol, standing order, prescription, or medical direction.

4. Screen for allergies, contraindications, relevant medical history, current medications, and medication already taken.

5. Verify the medication, concentration, dose, route, timing, expiration, packaging, and device integrity.

6. Administer or assist according to scope of practice.

7. Reassess the patient and document the medication, dose, route, time, indication, response, and any adverse effects.

The medication cross-check is a deliberate defense against errors. Confirm the right patient, medication, indication, contraindications, dose, route, time, expiration and integrity, response, and documentation. Use the protocol, medication label, dosing tool, or medical direction rather than relying on memory. When staffing permits, independently verify high-risk or unfamiliar medications with a second EMT.

Before administration, ask about medication allergies and prior reactions; prescriptions, over-the-counter drugs, and recreational drugs; the name, dose, route, and time of any medication already taken; and conditions such as asthma, diabetes, heart disease, pregnancy, bleeding disorders, or renal disease.

Assistance and administration

Medication assistance usually involves helping a patient take that patient’s prescribed medication, such as retrieving an inhaler or coaching device use. Medication administration means that the EMT gives the medication under an authorized protocol, standing order, or direct medical direction. Local law and policy determine the exact distinction.

Takeaway

Safe medication practice depends on assessment, authorization, contraindication screening, accurate preparation, reassessment, and objective documentation.

Routes and patient readiness

The route affects how quickly a medication is absorbed, how it acts, and what risks it creates. Never substitute a route because it seems convenient.

• Oral: The patient must be able to swallow and protect the airway. Avoid oral medication in an unconscious, actively vomiting, or severely altered patient.

• Sublingual: Place the medication under the tongue and do not swallow it. Check blood pressure and contraindications before assisting with nitroglycerin.

• Buccal: Place the medication between the cheek and gum. Vomiting or excessive secretions may interfere with absorption.

• Inhaled: The patient must be able to cooperate with an inhaler, spacer, or nebulizer when authorized and available.

• Intranasal: Use the unit-dose device correctly in the nostril. Severe nasal bleeding or obstruction may reduce delivery.

• Intramuscular: Use the correct device and weight range. An epinephrine auto-injector is used in the anterolateral thigh.

• Subcutaneous: Use this route only when specifically authorized and when the product is designed for it.

• Topical or transdermal: Wear gloves, avoid contact with medication residue, and do not remove or apply patches unless authorized.

A route of administration must match both the medication and the device. The patient’s ability to cooperate, swallow, breathe, and protect the airway is part of route selection.

Takeaway

Correct medication selection is not enough: the route, device, patient condition, and authorization must also match.

Dosing and repeat-dose decisions

Some medications use fixed-dose devices; others require a calculation. For weight-based dosing, use:

When a liquid concentration is supplied, calculate the volume as:

When weight is given in pounds, convert it using:

Recheck decimal points, units, concentration, pediatric weight, and the maximum dose. Confusing milligrams with micrograms or milliliters with milligrams can create a tenfold error. Follow the dosing tool, protocol, product label, or medical-control direction instead of estimating.

Children may need weight-based doses and pediatric-specific devices. Older adults may have altered medication metabolism, polypharmacy, or increased sensitivity to blood-pressure changes and sedating medications. For either group, confirm weight, medication history, and age-specific guidance.

Do not repeat a dose merely because improvement is not immediate. Check the minimum interval, maximum number of doses, vital-sign requirements, and medical-control instructions. If the patient worsens, rapid transport or advanced care may be more appropriate than repeated EMT-level medication.

Example

A labeled product may provide a fixed dose for one weight range and a different fixed dose for another. The EMT must verify the actual device and local protocol rather than selecting a device from memory.

Takeaway

Accurate dosing requires correct units, patient weight when relevant, concentration checks, maximum-dose checks, and protocol-based timing.

Medications for chest and respiratory complaints

Each common EMT medication has a specific role, and each requires indication and contraindication screening.

Aspirin

Aspirin is an antiplatelet medication that reduces platelet aggregation. When authorized, chewable aspirin may be appropriate for an alert adult with suspected acute coronary syndrome or another qualifying nontraumatic chest-pain presentation. A common authorized adult range is $162\text{–}325\,\text{mg}$, but local protocol controls.

Do not give aspirin when the patient has an aspirin allergy or serious prior reaction, active significant bleeding, an inability to swallow safely, or a medical instruction not to take it. Consider bleeding risk and recent aspirin use. Gastrointestinal irritation, bleeding, nausea, bronchospasm in susceptible patients, and allergic reactions are possible.

Nitroglycerin

Nitroglycerin is a nitrate vasodilator that can decrease myocardial oxygen demand and may improve coronary blood flow. It may be used for qualifying chest discomfort when prescribed for the patient or authorized by protocol. Many products provide $0.4\,\text{mg}$ sublingually per dose, but the product strength and repeat-dose rules must be verified.

Check blood pressure before and after assistance. Withhold and follow protocol or contact medical direction for low blood pressure, suspected right-ventricular infarction, recent phosphodiesterase-5 inhibitor use such as sildenafil or tadalafil, severe dehydration or shock, or allergy. Headache, flushing, dizziness, hypotension, syncope, and reflex tachycardia may occur.

Albuterol

Albuterol is an inhaled beta-2 agonist bronchodilator that relaxes bronchial smooth muscle. It is used for bronchospasm with wheezing or respiratory distress, commonly through nebulization or a metered-dose inhaler with or without a spacer. A commonly labeled adult nebulized dose is $2.5\,\text{mg}$, but concentration, age, repeat schedule, and EMT authority must be checked.

Use caution with hypersensitivity, inability to cooperate, severe tachycardia or dysrhythmia concerns, inability to maintain an airway, or significant cardiac disease. Tremor, nervousness, tachycardia, palpitations, headache, nausea, and rarely paradoxical bronchospasm may occur. Continue to assess work of breathing, oxygenation, fatigue, and possible respiratory failure even when wheezing improves.

Takeaway

Medication selection must be tied to the patient’s presentation and current safety checks; a familiar medication is not automatically appropriate.

Medications for anaphylaxis, overdose, and hypoglycemia

Epinephrine

Epinephrine is an alpha- and beta-adrenergic agonist. It causes vasoconstriction, increases cardiac stimulation, and relaxes bronchial smooth muscle. It is the priority medication for anaphylaxis or severe allergic reaction with airway swelling, respiratory distress, shock, or rapidly progressive multisystem involvement.

Use an intramuscular auto-injector in the anterolateral thigh. Many product labels associate $0.15\,\text{mg}$ with patients weighing from $15\,\text{kg}$ to less than $30\,\text{kg}$, and $0.3\,\text{mg}$ with patients weighing $30\,\text{kg}$ or more. Verify the actual device and local protocol. In life-threatening anaphylaxis, there is no absolute contraindication based on age, pregnancy, or cardiac history. Anxiety, tremor, pallor, headache, nausea, tachycardia, hypertension, and dysrhythmias may occur.

Naloxone

Naloxone is an opioid antagonist that reverses opioid-induced respiratory depression. It may be given intranasally, intramuscularly, or by another locally authorized route. A common intranasal product supplies a single $4\,\text{mg}$ dose in $0.1\,\text{mL}$, but product labeling and protocol determine repeat-dose timing.

For an apneic patient with a pulse, assisted ventilations and oxygenation have priority while naloxone is prepared. Naloxone may cause acute withdrawal, vomiting, agitation, sweating, tachycardia, or hypertension. Protect the patient and crew from sudden agitation, and monitor for recurrent respiratory depression as the opioid effect outlasts naloxone.

Oral glucose

Oral glucose is a rapidly absorbed carbohydrate for suspected hypoglycemia when the patient is awake enough to swallow and can protect the airway. Product concentration and package size vary, so follow the label and local protocol. Do not give it to a patient who cannot follow commands, cannot swallow, is actively vomiting, or has an unprotected airway. Nausea, vomiting, aspiration, and persistent or recurrent hypoglycemia are possible.

Oxygen

Oxygen is treated as a therapy rather than a medication in many EMS systems, but its use is commonly tested. Provide it for hypoxemia, respiratory distress, shock, or other protocol-defined indications. Select a device based on respiratory effort and oxygenation, titrate according to local guidance, and never allow oxygen administration to delay ventilation for inadequate breathing.

Takeaway

In anaphylaxis, opioid-induced respiratory depression, and unsafe hypoglycemia, support airway and breathing while using the indicated medication as an adjunct to, not a replacement for, life-saving care.

Reassessment, adverse effects, and documentation

Reassess after every medication. Compare the patient’s condition with the baseline assessment and look for both therapeutic and adverse effects. A medication may cause a predictable side effect, allergic reaction, toxicity, interaction, or paradoxical response.

If a serious adverse effect occurs:

• Stop further doses unless a protocol specifically directs otherwise.

• Support airway, breathing, and circulation.

• Monitor vital signs and mental status.

• Request advanced care or online medical direction when appropriate.

• Bring the medication container or device during transport.

• Document the reaction, treatment, and response.

Medication safety continues beyond administration. Secure medications and maintain appropriate storage conditions. Protect them from excessive heat, freezing, moisture, and contamination. Rotate stock and remove expired, damaged, or improperly stored products. Use infection-control precautions, avoid touching medication-contact surfaces, and never administer an unlabeled or unidentified medication.

Report medication errors immediately. Support the patient first, notify medical direction and the receiving facility, and document objectively. During handoff, communicate the medication name, dose, route, time, indication, response, and adverse effects. Include possible interactions with home medications, alcohol, illicit drugs, and medications given by bystanders or other responders.

Integrated decision example

A patient with suspected opioid overdose who is apneic but has a palpable pulse needs assisted ventilations and oxygenation immediately. Naloxone should be prepared without delaying respiratory support. After administration, reassess breathing, mental status, vital signs, and the possibility of withdrawal or recurrent respiratory depression.

Final takeaway

The complete EMT medication process is assessment, authorization, contraindication screening, accurate dosing, correct route, administration or assistance, reassessment, escalation when needed, and documentation.