January 30, 2026

Welcome to UH EMS-I’s Pharmacy Phriday. As we continue to look at recent changes to our UH EMS 2026 Protocols, we now focus on the medication ondansetron. This change resulted from the recent expansion of the Ohio Scope of Practice for EMS professionals. Click here for the Ohio Scope of Practice.  

Welcome to UH EMS-I’s Pharmacy Phriday. In the last installment, we reviewed changes within the 2026 protocols regarding ondansetron. This week, we focus on additional changes in the “Nausea/Vomiting” algorithm related to metoclopramide, typically the back-up medication provided to UH providers when ondansetron is not available. Metoclopramide is an antiemetic (though in a different class than ondansetron) often used in the treatment of gastric reflux, nausea/vomiting, and as a treatment in the ED for acute migraine headaches. 

As it relates to the nausea and vomiting complaints EMS often see, the medication is helpful as it enhances the effects of the neurotransmitter acetylcholine (ACH) on the upper GI tract which causes increased gastric motility and emptying of the stomach. In addition, it is a dopamine antagonist (blocks dopamine receptors). Dopamine is one of the neurotransmitters released by GI irritation that can cause nausea and vomiting, and blocking the receptor sites will reduce the symptoms or complaints.  

Dopamine also plays other roles in the brain, like controlling motor and cognitive functions. Metoclopramide’s effect in blocking dopamine can affect these other functions as well, causing altered levels of consciousness, impaired mental and physical abilities, and extrapyramidal symptoms (EPS). Any time these mentioned conditions already exist, or a depressant has caused similar symptoms, they should be considered a contraindication to metoclopramide. 

Due to increased GI motility caused by metoclopramide, it is also contraindicated when a patient is suspected of having a GI bleed, obstruction, or perforation. Epilepsy is also a contraindication to metoclopramide, as the medication is known to lower the seizure threshold in these patients. 

A final contraindication under the UH protocols includes the presence of QT prolongation greater than 500 ms (2.5 large EKG boxes) if noted on the patient’s EKG. This is a rare complication, but if an ECG has been completed and the QT interval is noted as prolonged, the medication should be withheld.

When considering the side effects of metoclopramide, the most concerning is akathisia, a feeling of restlessness or panic, and other EPS symptoms that can include involuntary muscle movements, often around the face. These side effects are more likely to be seen in diabetics, children, seniors, and those taking antipsychotic medications. In cases where these symptoms do occur, the provider is directed to administer Benadryl. 

Metoclopramide is described as a highly effective medication, but the above side effects are concerning. The changes in the protocol stress these concerns, highlighting the contraindications, cautions, and safety items more clearly (see an excerpt from the algorithm, page 84, below).  

The dosing of metoclopramide under the UH protocols is 10 mg given IV/IM and should be given as a slow push over two minutes to reduce the risks of akathisia. It is a fast-acting medication with an onset of about 1-3 minutes via the IV route and has a duration of 1-3 hours. There isn't a repeat dose recommended within the UH protocols. It is a medication given only by the paramedic provider, and only to an adult patient. Pediatric dosing is not recommended in the prehospital setting.

It is worth reminding all our providers that nausea and vomiting remain common complaints in emergency medicine, and that early treatment is good practice. It does not serve the patient or the crew well to wait until the patient begins vomiting before treatment! 

Until next week, stay safe!

The UH EMS-I Team 

University Hospitals

September 1, 2023

NFL’s 2023 pre-season has come to a close. The regular season starts next week! The fate of many players has been decided. Some made it as a starter. Some secured spots as backups. Others simply were cut or traded! In this installment of UH EMS Institute’s Pharmacy Phriday, we focus on Reglan, back-up to our popular starter Zofran for nausea and vomiting.  

Reglan is an antiemetic (though in a different class than that of Zofran) often used in the treatment of gastric reflux and nausea/vomiting. The medication enhances the effects of the neurotransmitter acetylcholine (ACH) on the upper GI tract, which causes increased gastric motility and emptying of the stomach. In addition, it is a dopamine antagonist (blocks dopamine receptors). Dopamine is one of the neurotransmitters released by GI irritation that can cause nausea and vomiting, and blocking the receptor sites will reduce the symptom or complaint.

Dopamine also plays other roles in the brain, controlling motor and cognitive functions, to name a few. Reglan’s effect in blocking dopamine can affect these other functions, causing altered levels of consciousness, impaired mental and physical abilities, and extrapyramidal symptoms (EPS). EPS symptoms are involuntary muscle movements, often around the face. 

Any time these mentioned conditions already exist or a depressant has caused similar symptoms, they should be considered as contraindications to Reglan’s use. Another contraindication to Reglan’s use is related to the medication’s actions within the body. Due to increased GI motility, it is contraindicated when a patient is suspected of having a GI bleed, obstruction, or perforation. Still, another contraindication is a history of epilepsy due to Reglan’s effect on lowering the seizure threshold, that can result in longer and more frequent seizures for the patient. 

A final contraindication under the UH protocols includes the presence of QT prolongation greater than 500 ms (2.5 large EKG boxes) if noted on the patient’s EKG. This is a rare complication, but if an ECG has been completed and the QT interval is noted as prolonged, the medication should be withheld. Refer back to our review of Zofran in week 2 of the 2023 Pharmacy Phriday series for further information on this topic.

Of all the side effects of Reglan, the most concerning is the extrapyramidal reactions that are more likely to occur in diabetics, children, seniors, and those already taking antipsychotic medications. In cases where EPS does occur, the provider is directed to administer Benadryl. 

The dosing of Reglan under the UH protocols is 10 mg given IV and should be given as a slow push over 2 minutes. It is a fast-acting medication with an onset of about 1-3 minutes via the IV route and has a duration of 1-3 hours. There is no repeat dose recommended. It is a medication only given by the paramedic provider and only to an adult patient. Pediatric dosing is not recommended in the prehospital setting.

It is worth noting to remind all our providers that nausea and vomiting remain a common complaint in emergency medicine, and it is good practice to treat patients early. It does not serve the patient or the crew well to wait until the patient begins vomiting before treatment!

Until next week, STAY SAFE!

Sincerely,



The UH EMS-I Team

University Hospitals