Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Drug Shortages Affecting EMS


 

The most recent FDA (Food and Drug Administration) listing of drug shortages, editing out the many cancer drugs, and other non-EMS drugs, includes the following:
 

Generic Name or Active Ingredient                                                 Status
 

Albuterol Sulfate Inhalation Solution (0.5%)         Resolved

This is important, but one way of dealing with a nebulized albuterol shortage is to alternate albuterol with nebulized saline. this prevents giving too much albuterol to the patient who is maintaining a reasonable oxygen saturation and keeping the airway humidified.
 

Atropine Sulfate Injection         Currently in Shortage

We should be accumulating atropine, since we no longer use atropine for asystole. Atropine maintains its strength, even when stored for extended periods, so we should only discard atropine when there is contamination.
 

Calcium Chloride Injection, USP         Currently in Shortage

Calcium (chloride or gluconate) appears to be the best drug for hyperkalemia. We are fortunate in EMS to not have to deal with sodium polystyrene (Kayexalate), which is just a means of creating the appearance of clostridium difficlie. Senna glycoside (ex-lax) can be just as effective at causing diarrhea and anything that causes diarrhea will cause some removal of potassium.
 

Calcium Gluconate Injection         Currently in Shortage

See above.
 

Cromolyn Sodium Inhalation Solution, USP         Currently in Shortage
 

Dexamethasone Sodium Phosphate Injection         Resolved
 

Dextrose 50% Injection         Currently in Shortage

We should be using 10% dextrose, rather than 50%, but we are slow to learn from our mistakes.

Comment on 10% Dextrose vs 50% Dextrose.
 

Epinephrine Injection, 0.1 mg/mL         Currently in Shortage

Maybe we will be using less epinephrine after the results of the Paramedic2 trial are published. I expect that some patients will be shown to benefit from epinephrine in cardiac arrest. I hope that the results will help us to identify which patients benefit from epinephrine in cardiac arrest and which patients have worse outcomes because of receiving epinephrine in cardiac arrest. I don’t really expect these answers, because we seem to be trying to avoid asking appropriate questions about drug treatment.
 

Epinephrine Injection, 1 mg/mL         Resolved
 

Fentanyl Citrate (Sublimaze) Injection         Currently in Shortage

There are other drugs that are effective for pain management. Hydromorphone (Dilaudid) can be used safely by EMS.
 

Labetalol Hydrochloride Injection         Currently in Shortage
 

Lidocaine Hydrochloride (Xylocaine) Injection         Currently in Shortage

EMS should have disposed of our supplies of lidocaine and amiodarone following the ALPS and PROCAMIO.

Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’

The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
 

Lidocaine Hydrochloride (Xylocaine) Injection with Epinephrine         Currently in Shortage

This is more for wilderness EMS, than urban.
 

Methylprednisolone Sodium Succinate for Injection, USP         Currently in Shortage

This is an important drug for reactive airway conditions.
 

Nitrous Oxide, Gas         Currently in Shortage

A lot of people are uncomfortable with the idea of using nitrous oxide, but it is safe – as long as there is good circulation of fresh air.
 

Pantoprazole (Protonix) Powder for Injection         Currently in Shortage

This is usually not the part of allergic reaction that EMS treats, but it can be helpful.
 

Potassium Chloride Injection         Currently in Shortage

Not generally prehospital EMS, but interfacility.
 

Procainamide Hydrochloride Injection, USP         Currently in Shortage

This is an antiarrhythmic drug that actually works, but we tend to avoid it out of a lack of understanding and a lack of familiarity with the evidence.
 

Promethazine (Phenergan) Injection         Currently in Shortage
 

Ranitidine Injection, USP         Currently in Shortage
 

Rocuronium Bromide Injection         Currently in Shortage

Succinylcholine may end up as a shortage because of the rocuronium shortage.
 

Sodium Bicarbonate Injection, USP         Currently in Shortage

After calcium, sodium bicarbonate can be effective for hyperkalemia. Flush the line. Even better, use a different line for these incompatible medications.

We should not be wasting sodium bicarbonate in cardiac arrest patients, since it is not going to do anything to make things better, but it will make it more difficult to get sodium bicarbonate for the patients who can actually benefit.
 

Sodium Chloride 0.9% Injection Bags         Currently in Shortage

Do we really need to start as many IV (IntraVenous) lines with a drip?
 

Sodium Chloride 23.4% Injection         Currently in Shortage

Also effective for hyperkalemia, since it is the sodium that moves the potassium, not any myth of alkalinizing the patient.

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