I rant a bit about the misuse of many of these drugs, but there are a lot of drugs used in EMS on the current drug shortage list.
There is a lot written about the drug shortages, but what drugs are affected right now? I copied a list of what drugs are currently experiencing shortages as of today from the FDA (Food and Drug Administration)., 
What about EMS drugs?
Alfentanil Injection (Alfenta, Rapifen) – An opioid that may be used in some EMS systems as a substitute for fentanyl. Or another reason for EMS to use ketamine.
Atracurium besylate (Tracrium) – A paralytic used in RSI (Rapid Sequence Induction/Intubation).
Atropine Sulfate Injection – Amphastar lists no delays, but other manufacturers list manufacturing delays and an increase in product demand. One manufacturer temporarily suspended production in April 2011.
The FDA search shows that there were drug shortages updates for atropine on 12/11/2008, 4/07/2009, and 9/30/2011 (the current shortage?), but all of the cached pages are the most recent, so the original information is not there.
Following concerns about possible terrorist attacks using poisons that may be treated with atropine, the long term stability of atropine, and the continuing lack of evidence of benefit of atropine in treating cardiac arrest.
How much did each of those contribute to another magic treatment biting the dust?
Caffeine, anhydrous (125 mg/mL) and Sodium benzoate (125 mg/mL) (Starbucks, Dunkin’ Donuts) – OK, that is not the kind of caffeine they are referring to. There might be true rebellion among EMS and hospital personnel if caffeine were not available.
What does that tell us about sleep deprivation, medicine, and the need for naps on the job?
Calcium Chloride Injection – If we are treating emergency hyperkalemia (which I recently saw written as hyperpotassiumemia :oops:) with anything other than calcium chloride as the first line drug, we are not providing good patient care.
But calcium is dangerous!!
The danger of calcium is just another EMS myth.
What is dangerous is using much less effective treatments, such as sodium bicarbonate.
What is even more dangerous is using harmful, but ineffective treatments, such as sodium polystyrene sulfonate (Kayexalate)
Calcium Gluconate – A less concentrated form of calcium, that is safer in IV (IntraVenous) lines of questionable patency, not that this is the biggest concern in treating peri-arrest patients. IO (IntraOsseous) works for calcium chloride.
Desmopressin Injection (DDAVP, Stimate, Minirin) – Similar to vasopressin.
Dexamethasone Injection (Decadron) – Methylprednisolone (Medrol, Solu-Medrol) is a good alternative that is not listed as a current drug shortage.
Diazepam Injection (Valium, Diastat) – The common alternative benzodiazepine sedatives (lorazepam [Ativan] and midazolam [Versed]) are also listed as current drug shortages.
Maybe this is a good reason to start carrying ketamine.
Digoxin Injection – An inotrope alternative to catecholamines. The only inotrope not supposed to raise heart rate or myocardial oxygen demand at therapeutic levels. On the other hand, there is debate about whether digoxin improves outcomes., 
Diltiazem Injection (Cardizem) – Verapamil (Calan, Isoptin, and Verelan) is the common alternative calcium channel blocker that should be used in the place of diltiazem for A Fib (Atrial Fibrillation) or SVT (SupraVentricular Tachycardia).
Diphenhydramine Hydrochloride Injection (Benadryl) – A medication to treat dystonic reactions. For dystonia, it can be replaced by benztropine (Cogentin). The more common use of diphenhydramine is as an antihistamine, such as after IM (IntraMuscular) epinephrine for anaphylaxis. It may sedate and decrease itching, but do not expect diphenhydramine to reverse anaphylaxis.
An example of dystonia. Image credit.
Etomidate Injection (New!!) (Amidate) – Etomidate is commonly used for pseudo-RSI or DFI (Drug Facilitated Intubation). In Pennsylvania, we have a dose of 0.3 mg/kg, that is often restricted even more by some medical command doctors out of an apparent fear of giving a dose that might be effective. Should they want to give orders for more, the maximum dose listed in the protocol is 30 mg. The medical command doctor can order more, but few seem to realize that this is not a restriction on what they can order. Etomidate is only supposed to be used with a paralytic for RSI, but is expected to be both sedative and paralytic, when EMS uses it in Pennsylvania. 😳
Why use a not-very-effective drug at a dose that is not expected to be effective?
Fentanyl Citrate Injection (Sublimaze) – The shortage of both benzodiazepines and opioids are just more reasons for EMS to use ketamine.
Furosemide Injection (Lasix) – A drug that EMS should not use. Furosemide is so far down on the list of treatments for CHF (Congestive Heart Failure), that it suggests we have been digging a grave for the patient, if we stay on scene long enough to give furosemide. A worthless EMS treatment.,  Pennsylvania is ahead of most states in moving furosemide to medical command order only, but the better move is to remove it from EMS use completely.
Ketorolac Injection (Toradol) – A pain medicine related to aspirin, so not a good idea for trauma, but some people are less worried about interfering with the ability of trauma patients to stop bleeding than they are about the possibility that the 10/10 severe pain patient might stop screaming and, without anyone noticing, stop breathing. 😳
One possible superiority is for calculi (kidney stones and gall stones). Of course, this is just another reason for EMS to use ketamine.
Labetalol Hydrochloride Injection (Normodyne, Trandate) – A beta blocker. Beta blockers have been de-emphasized since the CRUSADE trial, but there are still EMS indications in heart attack. Patients with signs of dramatic catcholamine release (they look as if someone gave them epinephrine) except for patients with tachycardia (greater than 110 beats per minute).
Lorazepam Injection (Ativan) – Not the best, or even the second best, EMS sedative, but one that is preferred by a lot of people. A much better idea is midazolam, because aggressive doses can be given and they should be wearing off at about the time the patient is being transferred to the ED (Emergency Department), so that one-on-one observation of a heavily sedated patient is not required and flumazenil (Romazicon) is not given. Another reason for EMS to use ketamine.
Magnesium Sulfate Injection – A safer antiarrhythmic than amiodarone and a treatment for some of the arrhythmias caused by amiodarone, such as torsades des pointes.-
Mannitol Injection – An osmotic diuretic used in some EMS systems.
Methylphenidate HCl (Ritalin) – Possibly the second most common EMS drug – after caffeine.
Metoclopramide injection (Reglan) – Anti-nausea medication.
Midazolam Injection (Versed) – This used to be my favorite EMS sedative, but this is one more reason for EMS to use ketamine.
Morphine Sulfate Injection – For pain management and another reason for EMS to use ketamine.
Nalbuphine Injection (Nubain) – A poor substitute for morphine and a pathetic excuse for risk management. Just another reason for EMS to use ketamine.
Naltrexone Oral Tablets (New!!) (Depade, ReVia) – With the use of nebulized naloxone, who knows what might be next? As long as we are treating something other than respiratory depression (patients unlikely to be able to use a nebulizer), maybe oral tablets will be next and the longer acting opioid antagonist may appeal to those terrified of any potential for respiratory depression.
NeoProfen (ibuprofen lysine) Injection – For treatment of PDA (Patent Ductus Arteriosus) in premature babies. Some EMS may use this, but it is more likely to be found in the ED or neonatal ICU.
Ondansetron Injection 2 mg/mL (Zofran) – One effective antiemetic.
Ondansetron Injection 32 mg/50 mL premixed bags (Zofran) – Same thing, different preparation.
Oxytocin Injection, USP (synthetic) (Pitocin) – For post-partum hemorrhage that is not otherwise controlled. Massage the fundus and consider direct pressure. Direct pressure is not in EMS protocols, but when the alternative is the death of the patient, do we want to stop the bleeding, or do we want to follow protocols?
Pancuronium Bromide Injection (Pavulon) – A paralytic used in RSI.
Phentolamine Mesylate for Injection (Regitine) – For treatment of extravasation of catecholamines (epinephrine, dopamine, dobutamine). Not usually carried by EMS (after all, it only happens in other EMS systems), but used in the ED (even to treat the extravasation of catecholamines from EMS IVs – but only from those other EMS systems). 😎
Procainamide HCL Injection (Pronestyl) – An antiarrhythmic that is very effective, but it has a lot of side effects – just like the much less effective drugs that are used in its place.
Prochlorperazine Injection (Compazine) – Another anti-nause medication. This is also one of the drugs that may cause dystonic reactions.
Promethazine Injection (Phenergan) – Still another anti-nause medication. Another drug that may cause dystonic reactions.
Vasopressin Injection (Pitressin) – An alternative to epinephrine as a pressor to treat cardiac arrest, even though there is no evidence of improved survival. Also goes by the name “pit,” so that it can be easily confused with Pitocin (“pit”) used in OB/GYN.
Vecuronium Injection (Norcuron) – A paralytic used in RSI.
That is it for the drugs that are used in some EMS systems. Fortunately, a lot can be replaced by ketamine, or their use can be reduced by the use of ketamine. Pain management, sedation, RSI, excited delirium, DSI (Delayed Sequence Intubation), et cetera. One long list of reasons for EMS to use ketamine.
Also see Stressful Drug Shortage Update.
 List of medications from FDA drug shortages update on 02/15/2012
Acetylcysteine Inhalation Solution
Alcohol Dehydrated (Ethanol > 98%)
Amino Acid Products (New!!)
Ammonium Chloride Injection
Ammonium Molybdate Injection
Ammonul (sodium phenylacetate and sodium benzoate) Injection 10%/10%
Amphetamine Mixed Salts, ER Capsules
Amphetamine Mixed Salts Immediate-Release Tablets
Anadrol-50 tablets (Oxymetholone Tablets)
Atropine Sulfate Injection
Avalide (irbesartan and hydrochlorothiazide)Tablets
Bupivacaine Hydrochloride Injection
Caffeine, anhydrous (125 mg/mL) and Sodium benzoate (125 mg/mL)
Calcitriol 1 mcg/mL Injection
Calcium Chloride Injection
Cerezyme (imiglucerase for injection)
Chromic Chloride Injection
Cisplatin injection 1 mg/mL solution
Corticorelin Ovine Triflutate (New!!)
Daunorubicin hydrochloride solution for injection
Diphenhydramine Hydrochloride Injection
Doxorubicin (adriamycin) lyophilized powder
Doxorubicin Liposomal (Doxil) Injection
Doxorubicin Solution for Injection
Ethiodol (ETHIODIZED OIL) ampules
Etomidate Injection (New!!)
Etoposide solution for injection
Fabrazyme (agalsidase beta)
Fentanyl Citrate Injection
Foscarnet Sodium Injection
Fosphenytoin Sodium Injection
Haloperidol Decanoate Injection
Indigo Carmine Injection
Insulin glulisine [rDNA origin] injection) solution for injection (Apidra SoloStar)
Intravenous Fat Emulsion
Labetalol Hydrochloride Injection
Leucovorin Calcium Lyophilized Powder for Injection
Levoleucovorin (Fusilev) 50 mg single use vials
Magnesium Sulfate Injection
Mesna 100 mg/mL Injection
Mexiletine Capsules (150mg, 200mg, and 250mg)
Mitomycin Powder for Injection
Morphine Sulfate Injection
Multi-Vitamin Infusion (Adult and pediatric)
Mustargen (mechlorethamine HCl) injection
Naltrexone Oral Tablets (New!!)
NeoProfen (ibuprofen lysine) Injection
Neupro (rotigotine transdermal system)
Ondansetron Injection 2 mg/mL
Ondansetron Injection 32 mg/50 mL premixed bags
Opana ER (oxymorphone hydrochloride) Extended-Release Tablets CII (New!!)
Orphenadrine Citrate Injection
Oxsoralen (methoxsalen) 1% topical lotion
Oxytocin Injection, USP (synthetic)
Pancuronium Bromide Injection
Phentolamine Mesylate for Injection
Phytonadione Injectable Emulsion (Vitamin K)
Primaquine Phosphate Tablets
Procainamide HCL Injection
Sodium Acetate Injection
Sodium Chloride 23.4%
Sodium Phosphate Injection
Sulfamethoxazole 80mg/trimethoprim 16mg/ml injection (SMX/TMP)
Telavancin (Vibativ) Injection
Thiotepa for Injection
Thyrogen (thyrotropin alfa) injection 1.1mg/vial
Tobramycin Solution for Injection
Vinblastine Sulfate Injection
Voltaren gel 1% (Diclofenac Sodium Topical Gel) (New!!)
 Comparison study of intraosseous, central intravenous, and peripheral intravenous infusions of emergency drugs.
Orlowski JP, Porembka DT, Gallagher JM, Lockrem JD, VanLente F.
Am J Dis Child. 1990 Jan;144(1):112-7.
PMID: 1688484 [PubMed – indexed for MEDLINE]
For many more years, digitalis continued to be an important part of heart failure management. The detrimental aspects of digoxin therapy were not considered important until excess mortality was reported in survivors of myocardial infarction who received digitalis.13,14 Uncontrolled observations that the withdrawal of digoxin produced no ill effects also raised concerns about the efficacy of the drug.15,16
 The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group.
[No authors listed]
N Engl J Med. 1997 Feb 20;336(8):525-33.
PMID: 9036306 [PubMed – indexed for MEDLINE]
In conclusion, digoxin had no effect on overall mortality in patients receiving diuretics and angiotensin-converting–enzyme inhibitors, but it did reduce the overall number of hospitalizations and the combined outcome of death or hospitalization attributable to worsening heart failure. In clinical practice, digoxin therapy is likely to affect the frequency of hospitalization, but not survival.
On the other hand, that is not a study of digoxin for emergency use.
 Prehospital therapy for acute congestive heart failure: state of the art.
Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK.
Prehosp Emerg Care. 2003 Jan-Mar;7(1):13-23. Review.
PMID: 12540139 [PubMed – indexed for MEDLINE]