Drugs and compromise levels

Question 1

Asthma levels of comprimise

Answer 1

Mild-moderate

• SOB
• able to speak in sentences
• usually have a loud wheeze
• no significant chest/neck indrawing
• normal SPO2
• normal LOC

Severe asthma

• very SOB
• only speaking a few WPB
• may only have a quiet wheeze
• significant chest/neck indrawing
• tripod positioning
• SPO2 usually above 90%
• may be agitated

Immediately life threatening

• extremely SOB
• unable to speak
• may not have wheeze
• marked indrawing, unless exhausted
• rapidly falling SPO2
• severe agitation
• falling LOC

Question 2

COPD levels of severity

Answer 2

Mild to Moderate 
-SOB
-able to speak in sentences
-usually have wheeze
-usually have some chest/neck indrawing
-SPO2 near normal level
-normal LOC
Severe
-very SOB
-only able to speak a few WPB
-may not have a wheeze
-usually have severe chest/neck indrawing
-tripod positioning
-SPO2 significantly below normal level
-may have agitation

Imminent respiratory Arrest

• extremely SOB
• unable to speak
• may not have a wheeze
• may not have chest/neck in-drawing as to fatigued
• SPO2 rapidly falling
• severe agitation or falling LOC.

Question 3

Cardiovascular Comprimise

Answer 3

NOT Comprimised
-normal vital signs
-no symptoms of myocardial ischaemia
-looks status 4
MILDLY comprimised
-near normal vital signs e.g near normal BP and CRT, normal LOC, , normal or near normal breathing
-mild symptoms of myocardial ischaemia
-looks status 3
MODERATELY comprimised
-abnormal vital signs e.g hypotension, prolonged CRT, altered LOC however can still obey commands, moderate SOB, significant symptoms of myocardial ischaemia
-looks status 2.
SEVERE comprimise
-markedly abnorma;l vital signs e.g severe hypotension, inability to obey commands, severe SOB
-high risk of CA
-looks status 1.

Question 4

compensating vs decompensated shock

Answer 4

COMPENSATING shock
-increased HR, RR, prolonged, pale clammy, diaphoretic, possibly agitated
However sympathetic NS response is maintaining and systolic BP has not dropped
DECOMPENSATED
fall in systolic BP, delayed CRT, very weak radial, increased HR, possible worsening agitation or dropping LOC.
Irreversible
metabolic acidosis, organ failure.
unconcious, HR dropping, BP unrecordable, periarrest.

Question 5

Valporate

Answer 5

I- status EP, with no response to 2x dose midaz
C-severe allergy
A-is an anticonvulsant, it blocks sodium channels and enhances activity of GABA at GABA receptors
R-IV only
D- 1200mg
S-none

Question 6

Tranexamic acid

Answer 6

I- PPH
-Hypovalemia from uncontrolled bleeding
-any other bleeding severe enough to need sodium fluids
C-known severe allergy
-trauma where administration will occur more than 3 hours after injury
A-it is an antifibriolytic.
It blocks the conversion of plasmogin to plasmin. (When plasmogin has been activated by a stimulus to convert to plasmin it begins to break fibrin clots).
R-IV
D-1g (10ml/1g)
S-none

Question 7

Tenecteplase

Answer 7

I-STEMI- when PCI is not chosen reperfusion strategy
A- fibronylictic- accelerates breakdown of clots, by causing plasmogin to be converted to plasmin which breaks down fibrin within clots.
S-bleeding and dysrhythmia (commonly can cause accelerated idioventricular)

Question 8

Sodium Bicarb 8.4%

Answer 8

I-release syndrome following crush injury
C-severe allergy, caution IV access in small vein
A-It is an alkalising agent and increases plasma bicarbonate levels by buffering H+ ions and it increases blood pH.
-sodium ions help protect cardiac cell membranes against effect of hyperkalemia
-a rise in pH causes a movement of potassium back into cells
-a rise in urinary pH results in less deposition in the kidneys
R-IV only- must be careful not to mix with other medications as can cause precipitation.
D-100mmol can repeat after 10-20 mins if signs of hyperkalemia persist.
S- none
Note- can also be used in TCA overdose if readily available

Question 9

salbutamol

Answer 9

I- asthma COPD
brochospasm secondary to smoke inhalation or airway burns or chest infection
-release syndrome following crush injury
C-severe allergy
A- beta 2 agonist- causes brochodilation
R- nebulised 
D- 5mg can repeat as required
S- tachycardia, tremor

Question 10

Ipratropium

Answer 10

I- asthma, COPD brochspasm secondary to airway burns, smoke inhalation or chest infection.

C- severe allergy
A- acts on antichollinergic receptors, so it blocks uptake of acetylcholine which causes inhibition of vagal stimulation and then bhronchdilation.
R-Nebulised
D-0.5mg- only one dose to be administered with salbutamol
S-dry mouth

Question 11

Fentanyl

Answer 11

I- moderate to severe pain, severe anxiety in CPO, symptom control in end of life care.
C–severe allergy, respiratory depression, unable to obey commands
Cautions at risk of respiratory depression, concurrent administration of other opiates, age less than 1, labour, signs shock, elderly or frail.
A- Stimulates (agonises) opiate receptors within the CNS and causes analgesia.
R-IV 10-50mcg every 5 mins
IM 50-100mcg repeat 1x 20 mins
IN <80kgs 100mcg subsequent dose 50mcg
>80kgs 200mcg subsequent dose 100mcg When administering 200mcg administer 1 ml in each nostrila nd then wait 5 minutes before administering the last 2 mls.
repeat 10mins
S-euphoria, respiratory depression, nausea/vomiting, bradycardia, hypotension, sedation, itch

Question 12

Aspirin

Answer 12

I- MI
C- severe allergy, third trimester pregnancy Cautions, clin sig bleeding, known bleeding disorder, bronchospasm from NSAIDS
A- antiplatelet, antipyretic, anti inflammatory, analgesic. Blocks production of cyclooxygenase which reduces formation of prostaglandin and thromboxane.
R 300mg

Question 13

Adrenaline

Answer 13

I-
clinically significant bleeding- topical
Anaphylaxis- 0.5mg repeat after 10 mins or earlier if required
Asthma-0.5mg repeat 10 mins if deteriorating
Epistaxis- IN 0.2mg in each nostril
cardiac arrest- 1mg every four mins, after amiodarone
Moderate to severe stridor-5mg Neb

C- none
Cautions, Myocardial ischaemia, tachydysrhythmia

A- Stimulates alpha and Beta receptors
Alpha- vasoconstriction of blood vessels, smooth muscle contraction, stimulates gluconeogenesis and glycogenolysis.
Beta 1- increases HR (chronotropy), cardiac contractility (inotropy), electrical conductivity (dromotropy)
Beta 2- smooth muscle relaxation, skeletal muscle vasodilation, bronchodilation, stabilisation of mast cells, reducing histamine release

S anxiety, tremor, tachycardia, tachydysrhythmia, MI, ventricular ectopy, nausea, vomiting, hyperglycaemia.

Question 14

Amoxiciclav

Answer 14

I- sepsis and
-more than 30 mins form hospital
-over 12 yrs old
- one or more high risk factor
Cellulitis with delay in seeing Dr
C- severe allergy, severe allergy to penicillin, anaphylaxis to betalactam antibiotics such as penicillins and cephalosphorins.
A- amoxicillin is a beta-lactam antibiotic. With a broad activity against gram negative a positive bacteria. It inhibits the production of bacteria cell walls, causing bacteria to die.
Clavuanic acid- inhibits a enzyme which is responsible for antibiotic resistance
R- IV dissolve using 4mls of saline and dilute to 10mls
D 1.2g- over 2 mins, preferable into a running line.

Question 15

Amiodorone

Answer 15

I- VT/VF in cardiac arrest after first dose of adrenaline

C-known severe allergy, severe allergy to iodine, VT secondary to TCA overdose

A- amiodarone is a class 3 anti-dysrhythmic with a broad range of activity.
It prolongs cardiac action potential, prolongs refractory period and reduces automaticity.
This decreases abnormal electrical activity. It also reduces electrical conduction, HR and stabilises SA and Av nodes
It also reduces myocardial oxygen consumption by reducing inotropy (cardiac contractility), although this is usually clinically insignificant.

R- IV
D-300mg second dose 150mg
S- hypotension, bradydysrhythmia

Question 16

Ceftriaxone

Answer 16

I-suspected meningococcal septicaemia
C-anaphylaxis to cephalosporins
A- ceftriaxone is a cephalosporin antibiotic with a broad range of activity against gram negative and gram positive bacteria. It inhibits bacterial cell wall production causing the bacteria to die.
R-IV add 4 ml of saline and dilute to 10 ml
IM add 4ml of saline and mix then draw up into 2 syringes and give into lateral thigh
D 2g

Question 17

Droperidol

Answer 17

I-Mild to moderate risk to safety when age over 12 years and olanzapine hasn’t been administered oh has been and is ineffective
C-severe allergy
Cautions, elderly, concurrent administration of other drugs, alcohol intoxication, Parkinson’s disease
A- Droperidol blocks dopamine and alpha receptors centrally, resulting in sedation and reduced agitation and a state of mental detachment.
R- IV or IM. Administer of 1-2 mins if IV.
D- 10mg or 5mg if pt is frail.
Repeat 20 mins
S-hypotension- especially is administered rapidly

Question 18

Gentamicin

Answer 18

I-sepsis with site of infection abdomen, urinary tract of unknown, and;
-more than 30 mins from hospital
-age over 12
-1 or more high risk factor present
C-severe allergy, pregnancy
A- gentamicin is an amino-glycoside antibiotic it has broad acitivity against gram negative bacteria. It inhibits bacterial cell protein synthesis.
R- IV, dilute to 10-12mls and give over 2 mins- preferably into running line.
D- <60kg 240mg
60-80kg 320mg
>80kg 400mg
S ototoxixity, renal impairment

Question 19

Glucagon

Answer 19

I- Hypoglycaemia when Iv or oral glucose cannot be given
C-severe allergy
A-Glucagon increase blood glucose levels by stimulating glycogenolysis which is the breakdown of glycogen into glucose, predominantly from the liver.
R IM
D 1mg 0.5mg for under 5 year old
S none

Question 20

GTN

Answer 20

I- MI, CPO, HTN in autonomic dysreflexia, and control of HTN in STEMI.
C- HR less than 40 or above 150
systolic BP less than 100
VT
severe allergy
Cautions, STEMI (however if left sided and HTN is present administer without caution) , small, frail or physiologically unstable, mitral or aortic stenosis, erectyle dysfunction medication, poor perfusion
A-GTN is a potent vasodilator. It decreases venous return to the heart which decreases preload and reduces afterload which reduces myocardial oxygen demand in the heart. It also vasodilates coronary arteries which increases coronary blood flow, however this is thought to be not clinically significant.
R-SL
D MI 0.4 every 3-5 mins or 10 mins if caution
CPO 0.8mg- dose and frequency can be increased provided the systolic BP is greater than 100.
AD 0.4-0.8mg
HTN 0.4-0.8mg
S-hypotension, headache, tachycardia, lightheaded

Question 21

GTN patch

Answer 21

CPO not responding to GTN SL
control of hypertension in
-Autonomic dysreflexia
-STEMI, prior to fibrinolysis
-Interhospital transfer of STEMI
-Interhospital transfer of Stroke

Dose 1 patch 0.5mg per hour
Apply patch to lateral upper arm

Effects from the patch will dissipate apprx 10-20 mins after patch has been removed.

Question 22

Ketamine

Answer 22

I- severe pain (in addition to the pain relief) for pain that is not controlled by opiates.
C- severe allergy, age less than 1
Cautions HTN, condidtions made worse by HTN, MI, active psychosis, concurrent administration of other drugs, elderly/frail, unable to obey commands
A- Ketamine is an analgesic. It is an NMDA receptor antagonist. NMDA is one of the bodies main excitory neurotransmitters. Inhibition of this results in analgesia at low doses, in higher doses it causes amnesia, sedation and anaesthesia.
R-Analgesia
IV 50-80 kg 20mg over 15 mins
>80kg 30mgs over 15 mins
IM/ PO 0.5mg per kg up to 50mg repeat 1x after 20mins
Severe Agitated delirium
50-80kg 200mg IM repeat 1x after 20 mins
>80kg 400mg
1mg/kg IV up to 100
S- HTN, tachycardia, apnoea, sedation, hallucinations, nausea vomiting

Question 23

Lignocaine

Answer 23

I- IO pain, prophylaxis of pain from IV cannulation, digit ring blocks
C-severe allergy, infection at site of injection. Caution on an anticoagulant (ring blocks only)
A- Lignocaine is a local anaesthetic it blocks the transmission of nerve impulses by blocking the movement of sodium ions across the nerve cell membrane.
R- IO, SC
D- IO upto 50mg 1x repeat after 15 mins. Administer over 1-2 mins and wait a further minute before infusing fluid.

SC up to 200mg. For ring block 1-2mls either side of digit. Repeat x1 after 30mins.
S-stinging at site of injection

Question 24

Midazolam

Answer 24

I- prolonged seizure, mild to moderate risk to safety agitated delirium when droperidol is not available or ineffective.
C-severe allergy Caution, concurrent administration of sedatives, elderly or frail, intoxication.
A- Midazolam is a benzodiazepine. It enhances GABA at GABA receptors within the CNS. GABA is one of the bodies inhibitory neurotransmitters. This results in anticonvulsant activity, sedation, anxiolysis, amnesia and muscle relaxant.
R- seizures IV 3-5 mg repeat 1x after 5 mins
IM 5- 10-mg repeat 1x after 10 mins
Agitated delirium 10mg IM
S-sedation, respiratory depression, hypotension, amnesia.

Question 25

Naloxone

Answer 25

I- suspected opiate overdose with impaired LOC and impaired breathing.
-excess adverse effects from opiate administration
C-severe allergy. Caution, chronic opiate use
A-Naloxone blocks opiate receptor, inhibiting the uptake of opiates within the CNS, this reverses the effects of opiates.
R-IM, IV
D -IV 0.2-0.4mg repeat every 5 minutes as required
-IM 0.8 mg repeat every 20 mins as required.
S-sweating, tachycardia, HTN

onset IV 1-2 mins
IM 5-10 mins

Question 26

Olanzapine

Answer 26

I- Aged over 12 years with mild to moderate risk to safety and willing to take oral medication
C- severe allergy, poisoning from antipsychotic medication. Caution, pregnancy, elderly and frail, intoxication.
A- antipsychotic with effects at multiple receptor in the brain, which results in decreased agitation, sedation, anxiolysis, and stabilisation of mood.
R-PO
D 10mg or 5mg if frail, repeat 1x 20 mins
S- sedation

Question 27

Ondansatron

Answer 27

I- clinically significant nausea and vomiting
C-severe allergy, age less than 1
A- antiemetic, blocks serotin reeptors in brain and GI tract resulting in a reduction in nausea and vomiting.
R- IV 8mg
IM 4mg repeat 1x 20 mins
S-headache, flushing

Question 28

Oxytocin

Answer 28

I-after vaginal birth, PPH
C-severe allergy
A-oxytocin is a synthetic version of oxytocin, which is a naturally occurring hormone which binds to oxytocin receptors and causes uterine contraction and reduces blood loss
R- IM
D-10 units (if PPH occurs a second dose should be given)
S flushing, abdominal craping, tachycardia

Question 29

Prednisone/ prednisolone

Answer 29

I- COPD/asthma, croup, anaphylaxis, minor allergy associated with rash
C-severe allergy. Caution, age less that 5 with asthma
A- is a corticosteroid with immunosuppressant and anti-inflammatory actions. It reduces inflammation by inhibiting the production of inflammatory mediators such as prostaglandins, and leukotrienes.
R-PO
D-40mg adult (if already taking prednisone, if dose is less than 40mg give them our dose and tell them to discontinue there prednisone and see GP within 2 days. If higher dose they shall just continue taking there own.)
S- fatigue, sodium and water retention, GI upset

Question 30

Agitated delirium

Answer 30

Mild to moderate risk to safety-

• verbally aggressive
• actions not involving immediate risk of serious harm to personnel, eg pushing and grabbing.
• pulling at equipment
• trying to climb of stretcher
• agitation preventing control of moderate external bleeding

Severe to immediately life threatening risk to safety

• dangerous physical aggression
• wielding a weapon
• actions such as punching or kicking
• destruction of physical surroundings
• trying to get out of moving ambulance
• preventing control of life threatening bleeding

Question 31

sepsis risk factors for over 12 year olds

Answer 31

High risk-
-objective evidence of new onset altered mental status
-known neutropenia
-respiratory rate >25 per minute
-systolic BP >100 or 40 below known normal
-HR >130
not passed urine in last 18 hours
-if catheterised passing less than 0.5ml/kg per hour
-mottled or ashen skin appearance
-cyanosis of skin, lips or tongue
-petechiae or purpura
Medium risk
-history from family/caregivers on new altered metal status
-acute deterioration of functional ability
-RR 21-24
-BP 91-100 sys
-HR 91-130
-new onset dysrythmia
-not passed urine in last 12-18 hours
-temp >36
-signs of skin/wound infection- redness, swelling
No risk
- normal mental status
-RR below 20
-BP above 100sys
-HR less than 90
- passed urine in last 12 hours.
-urine output more than 1ml/kg
1 high risk factor or 2 moderate risk factors- strong recommendation to be seen in GP, or seen by GP within 2 hours
1 moderate risk factor- seen by GP or primary care with 6 hours
- low risk factors, seen by GP in 24 hours

Question 32

Hyperthermia

Answer 32

MILD- temp 38-39 degrees, sweating, tachycardia, tachypnoea.
MODERATE- temp 49-40 degrees, sweating, tachycardia, tachypnoea, lethargy, feeling faint, nausea, vomiting, disorientation, muscle cramping
SEVERE temp >40, no sweating, hot dry skin, ALOC, signs of shock, confusion, dysthymias, seizures

Question 33

Hypothermia

Answer 33

MILD- temp 32-35 degrees, shivering, increased muscle tone, tachycardia, tachypnoea, HTN, poor coordination, lethargy, confusion
MODERATE- 28-32 degrees, bradycardia, bradypnea, aloc, hypotensive, absence of shiver
SEVERE- unconscious, severe bradypnea, severe bradycardia, severe shock, cardiac arrest, unequal pupils

People most at risk of hypothermia include outdoor environmental exposure or elderly or immobile who become exposed environment and cannot move, eg fall with NOF and home alone in winter.

Initial compensation of hypothermia is shivering and increased muscle activity and vasoconstriction. However once hypothermia becomes moderate cellular metabolism and cardiac function begins to slow down.