Medications We Don’t Use Any More

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Looking back over my career in EMS, I realized I could fill a drug box with medications that we don’t use any longer.

Some of these were used before I was a paramedic, but I was working as an EMT so I saw them in use and then be dropped.

Much of these were used before evidence based medicine made its debut in EMS.

They fell out of favor for a variety of reasons. Some had serious adverse effects, some were found to be not beneficial to the patient, some were replaced by better medications, and one stopped being made. At least one is back in favor. Many were used in the hospital even though EMS stopped using them.

In no particular order and with my unscientific observations, here they are.

Isuprel (Isuproterenol) This was used to generate some sort of cardiac electrical activity. It did that, but I don’t recall seeing it ever generate any actual cardiac activity. Generally, the medics gave it as a last ditch effort to resuscitate a patient.

Levophed. (norepinephrine bitartrate) Also known as “Leave ’em dead”. That should give you a hint of how well it worked. It was used when there was electrical activity, but no discernible blood pressure or pulse. I was discarded in EMS over 30 years ago, but was resurrected from the trash heap of EMS a couple of years back. Paramedics used to guesstimate the infusion rate, but now it’s only given with a pump.

Pitocin. It is used in the hospital to induce labor in women who are due, but aren’t going into labor as expected. It was used in EMS to stop post partum bleeding, but given the rarity of severe post partum bleeding, it really didn’t have much benefit. No one in EMS has ever wanted to induce labor, as we’d much rather that the birth take place in a nice clean hospital.

Decadron. An IV infused steroid that was used for acute spinal cord injury. The idea being that infusing a steroid early on would limit swelling in spinal cord injury and maybe reverse of prevent paralysis. There is some evidence that this works in the hospital, but given the short transport times my system had, it was felt that it would be better for the patient to prioritize transport to a trauma center over treatment on scene. The demise of Decadron coincided with the initiation of formal trauma centers in Sorta Big City.

Bronkosol. The first nebulized Beta Agonist for treatment of Asthma and COPD. It was mostly Beat 2 (lungs), but had significant Beta 1 (cardiac) effects that sometimes made it dicey to use. Some patients, particularly older ones, had hypertention and tachycardia. Neither of which are particularly good for older patients. Still, it was better than other treatments.

Metaproterenol. This was the replacement of Bronkosol. It was supposed to have fewer side effects, but it still had some risk. We used this for patients that for some reason couldn’t take Albuterol, which was the replacement drug. Albuterol is still used and is very effective.

Verapamil. This was used to treat Atrial Fibrillation. It worked for that, but had serious side effects. Using this drug always made me nervous as hell. It’s still used, but not in EMS. At least I don’t think it’s still used in EMS. It’s a calcium channel blocker and had to be administered slowly to avoid adverse effects. One of which was acute hypotension. Which could be very hard to reverse. Also, it could not be used in cases where the rhythm might actually be Ventricular Tachycardia. So, we never used in case of wide complex tachycardia. The reason being that if it was VT, then the patient would go into refractory Ventricular Fibrillation. As in it would kill them. Just as Cricket players never want to got LBW, you never want to put your patient into refractory VF.

Bretylium. This was an anti arrhythmic used to treat Ventricular Tachycardia or Ventricular Fibrillation that didn’t respond to Lidocaine. Note, it would not work if the patient had been given Verapamil in error. Nothing would work if the patient was in refractory VF. Which is why it’s called refractory. It could be used on patients with pulses, but had the nasty side effect of sometimes inducing vomiting.

It was eventually removed because it wasn’t proven to actually work. Plus, there was an ongoing shortage of the raw materials from which it was made. I don’t know what the secret ingredient was, but it matters not as it’s out of production.

High Dose Epinephrine. This was used in cardiac arrest in the vain hope that it would restore a pulse to patients in Asystole. It didn’t although it did restore electrical activity. The truth is you could get electrical activity out of a piece of hamburger if you dumped enough Epinephrine into it. It’s use was mercifully short lived in EMS.

Valium. It’s still used in some systems, but my former system dropped it some time back. It was mostly replaced by Ativan, which is now out of the drug boxes as well, replaced by Versed.

All three are benzodiazepines, used either for procedural sedation or to treat seizures. The main different being in how long they last. For reasons that escape me, the doctors want EMS to only use short acting benzos.

Lasix. We used to use a lot of Lasix. It’s a diuretic, which means that it increases urine production. We used to use it for treatment of Congestive Heart Failure. It had no real adverse effects, but as it turned out, it didn’t work very well. As it turned out, CPAP and Nitroglycerine work a lot better. About ten years ago, there was a Lasix shortage and nobody noticed. At least nobody noticed in EMS, and patient who were on oral Lasix found some other medications that worked better.

Morphine. Originally, this was used along with Lasix as part of the CHF treatment regimen. It too was found to be ineffective. It was also used for cardiac chest pain. It was effective, only our protocol didn’t allow us to use enough of it to really relieve the pain. The doctors, and I’m not making this up, were afraid that we’d overdose the patients and they’d stop breathing. Or maybe that we’d overdose them and their blood pressures would drop. Ironically, we had treatments for both issues.

As it happens, Fentanyl is much better at relieving cardiac chest pain, orthopedic injury pain, and pain from burns. Which Morphine, at least in the doses we’d give, wasn’t very good at.

On a side note, the Morphine Syrettes that US soldiers were issued in World War II contained 30mg of Morphine. Our protocol allowed “up to” 10mg, but there’s was intramuscular and ours was intravenous. As it happened, there were several cases of overdose during World War II. Which may, may note have, affected the restrictions on our use.

Thiamine. We gave thiamine (B12) as part of the “Coma Cocktail” that came directly out of the Emergency Room. The Coma Cocktail was Narcan, Dextrose, and Thiamine. This was in the days before there were glucometers, so it was given blind. The Thiamine was administered to prevent Wernicke-Korsakoff syndrome. I’ll let you look that one up. Eventually, and I mean after my 35 years of active EMS, it was removed from the protocols because no one could recall a case of Wernicke-Korsakoff syndrome. Or spell it.

Two more drugs that are still used, but might not be for long.

Atropine. Used to be widely used in Asystole and Pulseless Electrical Activity (PEA). It’s not used in either any longer as there was never any evidence it worked. It’s still used in symptomatic bradycardia, but I’ve never been convinced it works all that well there, either.

Epinephrine. It’s used for Asystole, Ventricular Fibrillation, severe bradycardia, severe Asthma, and anaphylaxis. It’s use in Asystole is questionable and there is a large trial going on in London to see if it actually works.

There are probably others that I’ve forgotten, but those are the big gone and forgotten in EMS drugs. Who knows? Some of them may come back again. Or not.

2 COMMENTS

  1. My system recently (last protocol update) added Levophed and Pitocin, as well as Decadron for pedi asthma. Valium was abandoned yeard ago in favor of Versed, but now it’s back as an option.

    Everything old is new again?

    • Yes, these things seem to be cyclical. I’m half expecting Bicarb to come back!

      A lot depends on the proximity of capable hospitals versuse, uh, not so capable hospitals. I was fortunate to work in a system with lots of hospital resources. Other people work in systems where the nearest teaching hospital is an hour or more away.

      Levophed is back in our system mainly because Sepsis, although I think it’s in the cardiac arrest and shock protocols. Pitocin isn’t, but who knows what the next revision out of the puzzle palace will hold.

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