PHENERGAN VS. ZOFRAN ~Protocol update. A SPECIAL thank you for helping this project get completed: Evans Mutua, SN4 Jill Schrader, NREMT-P, SN4

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1 PHENERGAN VS. ZOFRAN ~Protocol update. A SPECIAL thank you for helping this project get completed: Evans Mutua, SN4 Jill Schrader, NREMT-P, SN4

2 To complete for Continuing Education Go thru the powerpoint presentation Complete the quiz at the end. We will send you 2 hours of continuing education once we receive your quiz.

3 Pharmacology: Phenergan DOPAMINE ANTAGONIST Minimizes the effects of dopamine at the D2 receptor sites which limits emetic input to the medullary vomiting center Can cause sedation, orthostatic hypotension, EPS symptoms: Tardive dyskinesia (tremors), Slurred speech, Akathisia (restlessness; inability to remain still or increased urge to move) and Dystonia (Muscle spasm, rigidity or rolling of eyes)

4 Pharmacology: Phenergan ANTIHISTAMINE Inhibits action of histamine at the H1 Receptor cells in the vestibular region which is rich in histamine Can cause confusion, sedation, dizziness, tinnitus, insomnia, incoordination, fatigue and tremors OTHERS Due to sedative effects, Phenergan is also considered a sedative/hypnotic Has anticholinergic properties

5 Pharmacology: Phenergan Sedation ADVERSE EFFECTS Vascular damage/necrosis in cases of extravasation Respiratory depression when combined with narcotics (e.g. morphine) or alcohol (ETOH) Hypertension with patients taking MAOI s (e.g. Nardil)

6 Pharmacology: Zofran SEROTONIN ANTAGONIST Inhibits action of serotonin at the 5- hydroxytryptamine 3(5-HT3) receptor sites in small bowel, vagus nerve, and chemoreceptor trigger zone Decreases stimulation of the visceral and chemoreceptor trigger zone in the medullary vomiting center

7 Pharmacology: Zofran ADVERSE EFFECTS Cardiac: QT prolongation and QRS widening Can cause hypersensitivity reaction

8 Summary: Phenergan Vs. Zofran

9 Phenergan vs. Zofran in Clinical Trials Braude: RCT P=sedation, akathisia, equal N/V relief Patanwala: literature review of 4 RCTs, P=sedation, recommends Z as first-line antiemetic Patka: Zofran good for pre-treatment of nausea, phenothiazines may control nausea longer, both controlled immediate nausea equally

10 Clinical Trial Summary Studies show Phenergan and Zofran control nausea at equal levels when reassessed at a 30 minute window. Zofran was shown to be more effective than Phenergan for prophylactic treatment of nausea; example: when used before chemotherapy Studies show that Zofran is safer, with less side effects than Phenergan. The sedation produced by Phenergan can be therapeutic in some cases but for most patients Zofran is recommended as firstline antiemetic. In some studies Phenergan produced akathisia in a few patients which is never therapeutic.

11 EMS Issues with Phenergan Sedation: Unknown etiologies of n/v, underlying medical conditions, possible interactions with home medications and use with alcohol Risk of Tissue Necrosis, dilution, slow IVP Price: Zofran is no longer more expensive

12 EMS Benefits of Zofran Based on the safety and efficacy of Zofran, it may be used as a first-line agent for relief of nausea or vomiting for most populations in the ED (Patanwala, 2009) No risk of tissue necrosis if IV infiltration; not a local irritant so will not need to dilute Can use in patients who have consumed alcohol Can administer to patients who also need narcotic pain control like morphine Less risk of drug interactions and unnecessary sedation

13 NEW PROTOCOL For ADULT patients complaining of nausea or vomiting, administer 4mg Zofran IV push May repeat the dose in 15 minutes if needed Note: You may administer Zofran if the patient is nauseated but has not yet vomited Patient must be complaining of nausea; current protocol is not for prophylactic treatment of nausea

14 Precautions For PEDIATRIC patients, must contact medical control prior to administration of Zofran Use with caution with patients concurrently using drugs which effect QT interval (i.e., Procainamide, amiodarone, TCA s, Haldol) Use with caution with hepatic impairment (consider prolonging dosage intervals or decreasing dose)

15 Contraindications Hypersensitivity to the drug Prolonged QT syndrome Concurrent use of Apomorphine (Apokyn), an antiparkinsonian drug (increases the risk of hypotension and syncope)

16 Side Effects Headache Constipation Diarrhea Hypotension Tachycardia Torsades de Pointes; changes in the morphology of QRS from beat to beat (rare)

17 So let s see what we changed in the QAEMS system Review the following policies: MP-28 Nausea and Vomiting O-14 EMS Drug box Supply List O-13-F.2 EMS Drug box Restock list M-1.29 Zofran

18 MP-28 Nausea/Vomiting Our preferred Medication for N/V will now be Zofran 4 mg slow IV push. You may repeat one additional dose if needed in 15 minutes. We will still be carrying Phenergan and can be given 12.5 mg (diluted in 10cc NS)slow IVP. You may repeat one additional dose if needed in 15 minutes. DO NOT SWITCH BACK AND FORTH BETWEEN THE MEDICATIONS. CONTACT MED CONTROL IF YOU FEEL YOU NEED TO SWITCH MEDICAITONS!

19 MP-28 Nausea/Vomiting PEDIATRICS Zofran : Must Contact Medical Control prior to administration Phenergan: Must contact Medical Control prior to administration 0.25 mg/kg (diluted in 10 cc NS) slow IVP NO ANITEMETIC SHOULD BE GIVEN TO A PEDIATRIC PATIENT UNDER THE AGE OF 2

20 Drug boxes Zofran will be carried in 2mg/ml injectables 2ml vials. Phenergan will be carried in 25mg injectables

21 Remember When calling in your patient report remember to notify the ED that you have given a Anitemetic so they can be prepared to insert an NG tube if needed.

22 Complete the attached quiz Complete that attached quiz to assure we can get the Zofran on the ambulance and in use as soon as possible.

23 Take the Quiz Online orms.aspx?formid=35130&sid=1

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