Emergency drugs

Question 1

Hydrocortisone

Answer 1

100-300mg IV in allergy

Initially 100 mg for 1 dose, then (by continuous intravenous infusion) 200 mg/24 hours, dilute in Glucose 5% in adrenal crisis

100 mg every 6 hours until conversion to oral prednisolone is possible, dose given, preferably, as sodium succinate asthma

Question 2

Epinephrine/adrenaline dose

Answer 2

500 micrograms, using adrenaline 1 in 1000 (1 mg/mL) injection, repeat dose after 5 minutes if no response; if life-threatening features persist, further doses can be given every 5 minutes until specialist critical care available, to be injected preferably into the anterolateral aspect of the middle third of the thigh. High flow O2 also

Cardiopulmonary rhesus- IV 1 mg every 3–5 minutes as required of 100 micrograms/mL solution

Question 3

Chlorphenamine

Answer 3

10 mg for 1 dose, to be repeated if necessary; maximum 4 doses per day. For anaphylaxis, IV or IM

Question 4

Atropine post MI bradycardia

Answer 4

500 micrograms every 3–5 minutes; maximum 3 mg per course. IV

Question 5

Aspirin

Answer 5

Secondary CVS prevention 75 mg once daily oral tablet

300mg one dose ACS (oral chewed or dispersed in water)

Question 6

Clopidogrel

Answer 6

Secondary prevention of transient ischaemic attack/stroke [in patients without atrial fibrillation], 75mg OD oral

Pre PCI (adjunct with aspirin) Loading dose 300 mg for 1 dose, to be taken prior to the procedure, oral

TIA/stroke Initially 300 mg for 1 dose, to be started within 24 hours of onset of symptoms, then 75 mg once daily. oral tablet

ACS without ST elevation - Initially 300 mg for 1 dose, then 75 mg once daily for up to 12 months. oral

ACS with ST elevation, 75 mg once daily for at least 4 weeks. oral

Question 7

Calcium gluconate

Answer 7

Severe acute hypocalcaemia or hypocalcaemic tetany, slo IV injection, Initially 10–20 mL, calcium gluconate injection 10%. Repeated as required

Acute severe hyperkalaemia [plasma-potassium concentration 6.5 mmol/litre or greater, or in the presence of ECG changes], slow IV injection, 30 mL, calcium gluconate 10% (providing approximately 6.8 mmol of calcium) should be administered as a single dose, repeat dose if no improvement in ECG within 5 to 10 minutes.

Question 8

Insulin/dextrose infusion

Answer 8

Insulin-dextrose protocol. Our local protocol required IV administration of 10 U regular insulin with 25 g of glucose as 50 mL of 50% dextrose.

For hyperkalaemia - Administer as follows: Transfer 100 units in 1ml insulin from insulin syringe into 10 ml syringe and make up to 10 ml using sodium chloride 0.9%. Add 0.5 ml of the diluted insulin solution to a 500 ml bag of glucose 10%. Label as per Trust policy. Set pump to run at 360 ml/ hour for 10 minutes only.

Question 9

Hypoglycaemia

Answer 9

15–20 g glucose

Adults with symptoms of hypoglycaemia who have a blood-glucose concentration greater than 4 mmol/litre, should be treated with a small carbohydrate snack such as a slice of bread or a normal meal, if due.

Any patient with a blood-glucose concentration less than 4 mmol/litre, with or without symptoms, and who is conscious and able to swallow, should be treated with a fast-acting carbohydrate by mouth. Fast-acting carbohydrates include Lift® glucose liquid (previously Glucojuice®), glucose tablets, glucose 40% gels (e.g. Glucogel®, Dextrogel®, or Rapilose®), pure fruit juice, and sugar (sucrose) dissolved in an appropriate volume of water.

If necessary, repeat treatment after 15 minutes, up to a maximum of 3 treatments in total. Once blood-glucose concentration is above 4 mmol/litre and the patient has recovered, a snack providing a long-acting carbohydrate should be given to prevent blood glucose from falling again - do not omit insulin if due

Hypoglycaemia which does not respond (blood-glucose concentration remains below 4 mmol/litre after 30–45 minutes or after 3 treatment cycles), should be treated with intramuscular glucagon 1mg or glucose 10% intravenous infusion if not effective after 10 mins

or glucose 20% intravenous infusion

By intravenous injection into large vein
ADULT 75–100 mL infused over 15 minutes

Question 10

Diazepam

Answer 10

Convulsive (including febrile) seizures lasting longer than 5 minutes

Either diazepam rectal solution (2 mg/mL, 4 mg/mL). ADULT 10–20 mg, repeated once after 5–10 minutes if necessary.

or midazolam oromucosal solution. ADULT 10 mg, repeated once after 5–10 minutes if necessary [unlicensed]

Question 11

Meningococcal disease

Answer 11

Benzylpenicillin sodium injection (600 mg, 1.2 g)

or if history of allergy to penicillin

Cefotaxime injection (500 mg, 1 g, 2 g)

Question 12

Angina: unstable, NSTEMI

Answer 12

Aspirin dispersible tablets (75 mg, 300 mg)

By mouth (dispersed in water or chewed)
ADULT 300 mg
Plus

either glyceryl trinitrate aerosol spray (400 micrograms/metered dose)

Sublingually
ADULT 1–2 sprays, repeated as required
or glyceryl trinitrate tablets (300 micrograms, 500 micrograms, 600 micrograms)

Sublingually
ADULT 0.3–1 mg, repeated as required

Question 13

Myocardial infarction: ST-segment elevation

Answer 13

MONA IV

Aspirin dispersible tablets (75 mg, 300 mg)

By mouth (dispersed in water or chewed)
ADULT 300 mg
Glyceryl trinitrate aerosol spray (400 micrograms/metered dose)

Sublingually
ADULT 1–2 sprays, repeated as required
or glyceryl trinitrate tablets (300 micrograms, 500 micrograms, 600 micrograms)

Sublingually
ADULT 0.3–1 mg, repeated as required
Metoclopramide hydrochloride injection (5 mg/mL)

By intravenous injection
ADULT 18–19 YEARS (BODY-WEIGHT UP TO 60 KG): 5 mg
ADULT 18–19 YEARS (BODY-WEIGHT 60 KG AND OVER): 10 mg
ADULT OVER 19 YEARS 10 mg
Diamorphine hydrochloride injection (5 mg powder for reconstitution)

By slow intravenous injection (1–2 mg/minute)
ADULT 5 mg followed by a further 2.5–5 mg if necessary
ELDERLY or FRAIL patients, reduce dose by half
or morphine sulfate injection (10 mg/mL)

By slow intravenous injection (1–2 mg/minute)
ADULT 5–10 mg followed by a further 5–10 mg if necessary
ELDERLY or FRAIL patients, reduce dose by half
Oxygen, if appropriate

Question 14

Asthma: acute

Answer 14

High-flow oxygen should be given if available (via tight-fitting face mask in children) to achieve and maintain an SpO2 level of 94‑98%.

Either salbutamol aerosol inhaler (100 micrograms/metered inhalation)

By aerosol inhalation via large-volume spacer. 2-10 puffs every 10-20 mins

or salbutamol nebuliser solution (1 mg/mL, 2 mg/mL). ADULT 5 mg every 20–30 minutes or as necessary

either prednisolone tablets (or prednisolone soluble tablets) (5 mg). ADULT 40–50 mg once daily for at least 5 days

or hydrocortisone (preferably as sodium succinate). By intravenous injection. ADULT 100 mg every 6 hours until conversion to oral prednisolone is possible

While awaiting ambulance, repeat nebulised beta2 agonist (as above) and give with

Ipratropium bromide nebuliser solution (250 micrograms/mL). ADULT 500 micrograms every 4–6 hours as necessary

Question 15

Croup

Answer 15

Dexamethasone oral solution (2 mg/5 mL)

By mouth
CHILD 1 MONTH–2 YEARS 150 micrograms/kg as a single dose

Question 16

lorazepam

Answer 16

Status epilepticus,
Febrile convulsions,
Convulsions caused by poisoning

Adult
4 mg for 1 dose, then 4 mg after 5–10 minutes if required for 1 dose, to be administered into a large vein.

Question 17

Salbutamol nebuliser

Answer 17

Moderate, severe, or life-threatening acute asthma

Adult
5 mg, repeat every 20–30 minutes or when required, give via oxygen-driven nebuliser if available.

Question 18

Prednisolone

Answer 18

Mild to moderate acute asthma,
Severe or life-threatening acute asthma
for prednisolone

Adult
40–50 mg daily for at least 5 days.

Question 19

Morphine

Answer 19

Acute pain - By mouth, or by subcutaneous injection, or by intramuscular injection

Adult
Initially 10 mg every 4 hours, adjusted according to response, subcutaneous injection not suitable for oedematous patients, dose can be given more frequently during titration, use dose for elderly in frail patients.

By slow intravenous injection

Adult
Initially 5 mg every 4 hours, adjusted according to response, dose can be adjusted more frequently during titration, reduced dose recommended in frail and elderly patients.

MI - By slow intravenous injection

Adult
5–10 mg, followed by 5–10 mg if required, dose to be administered at a rate of 1–2 mg/minute, use dose for elderly in frail patients.
Elderly
2.5–5 mg, followed by 2.5–5 mg if required, dose to be administered at a rate of 1–2 mg/minute.

Question 20

Naloxone

Answer 20

Acute opioid overdose–high-dose regimen [when rapid titration with naloxone is necessary to reverse potentially life-threatening effects]

Adult
Initially 400 micrograms, then 800 micrograms for up to 2 doses at 1 minute intervals if no response to preceding dose, then increased to 2 mg for 1 dose if still no response (4 mg dose may be required in seriously poisoned patients), then review diagnosis; further doses may be required if respiratory function deteriorates following initial response, intravenous administration has more rapid onset of action, doses may be given by intramuscular route but only if intravenous route is not feasible.

Question 21

Principles of IV fluid prescribing

Answer 21

Intravenous (IV) fluids should only be prescribed for patients whose needs cannot be met by oral or enteral routes. Where possible oral fluid intake should be maximised and IV fluid only used to supplement the deficit.

Examples of when IV fluids may be required:

A patient is nil by mouth (NBM) for medical/surgical reasons (e.g. bowel obstruction, ileus, pre-operatively)
A patient is vomiting or has severe diarrhoea
A patient is hypovolaemic as a result of blood loss (blood products will likely be required in addition to IV fluid)

Question 22

IV fluid types

Answer 22

IV fluids can be categorised into 2 major groups:

Crystalloids: solutions of small molecules in water (e.g. sodium chloride, Hartmann’s, dextrose)
Colloids: solutions of larger organic molecules (e.g. albumin, Gelofusine)
Colloids are used less often than crystalloid solutions as they carry a risk of anaphylaxis and research has shown that crystalloids are superior in initial fluid resuscitation.

Question 23

main fluids used

Answer 23

Question 24

fluid history

Answer 24

Fluid intake:

Assess if the patient’s fluid intake been adequate.
Symptoms suggestive of dehydration:

Thirst
Dizziness/syncope
Fluid loss:

Vomiting (or NG tube loss)
Diarrhoea (including stoma output)
Polyuria
Fever
Hyperventilation
Increased drain output (e.g. biliary drain, pancreatic drain)
Co-morbidities:

Heart failure
Renal failure

Question 25

fluid exam

Answer 25

Airway
Is the airway patent?
Breathing
Respiratory rate and oxygen saturation
Auscultate the lung fields
Findings suggestive of hypervolaemia include:

Increased respiratory rate (>20 breaths per minute)
Decreased oxygen saturations
Bilateral crackles on auscultation
Circulation
Pulse and blood pressure
Capillary refill time
Jugular venous pressure (JVP)
Peripheral oedema
Findings suggestive of hypovolaemia include:

Increased heart rate (>90 bpm)
Hypotension (systolic BP <100 mmHg)
Prolonged capillary refill time
Non-visible JVP
Findings suggestive of hypervolaemia include:

Hypertension
Elevated JVP
Disability
GCS
Findings suggestive of hypovolaemia include

Decreased GCS may be noted if the patient is significantly volume depleted.
Exposure
Wounds
Drains
Catheter output
Abdominal distension/peripheral oedema
Fluid balance charts/weight charts
Other losses (e.g. rectal bleeding)

Question 26

examination findings

Answer 26

Findings suggestive of hypovolaemia include:

Increased output from wounds and drains
Decreased urine output (<30mls/hr)
A fluid chart showing a negative fluid balance
Weight loss
Other sources of fluid loss (e.g. rectal bleeding, diarrhoea, vomiting)
Findings suggestive of hypervolaemia include:

Increased urine output
Abdominal distension (ascites) and peripheral oedema
A fluid chart showing a positive fluid balance
Weight gain

Question 27

if hypovolaemic

Answer 27

Initial fluid bolus

1. Administer an initial 500 ml bolus of a crystalloid solution (e.g NaCl 0.9%/Hartmann’s solution) over less than 15 minutes.
2. After administering the initial 500 ml fluid bolus you should reassess the patient using the ABCDE approach, looking for evidence of ongoing hypovolaemia as you did in your initial assessment (if you find yourself unsure about whether any further fluid is required you should seek senior input).
3. If the patient still has clinical evidence of ongoing hypovolaemia give a further 250-500 ml bolus of a crystalloid solution, then reassess as before using the ABCDE approach:

You can repeat this process if there is ongoing clinical evidence suggestive of the need for fluid resuscitation up until you’ve given a total of 2000 ml of fluid.

Question 28

fluid requirements

Answer 28

Daily maintenance fluid requirements (as per NICE guidelines):

25-30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50-100 g/day of glucose to limit starvation ketosis (however note this will not address the patient’s nutritional needs)

Question 29

fluid factors

Answer 29

Obese patients
When prescribing routine maintenance fluids for obese patients you should adjust the prescription to their ideal body weight. You should use the lower range for volume per kg (e.g. 25 ml/kg rather than 30 ml/kg) as patients rarely need more than 3 litres of fluid per day.

Other patient groups where you should consider prescribing less fluid
For the following patient groups you should use a more cautious approach to fluid prescribing (e.g. 20-25 ml/kg/day):

Elderly patients
Patients with renal impairment or cardiac failure
Malnourished patients at risk of refeeding syndrome

Question 30

redistribution causes

Answer 30

Patients can have issues with fluid distribution (e.g. fluid in the wrong compartment) and a collection of other complex issues which should also be considered prior to prescribing IV fluids:

Gross oedema
Severe sepsis
Hypernatraemia/hyponatraemia
Renal, liver and/or cardiac impairment
Post-operative fluid retention and redistribution
Malnourishment and refeeding issues
You should seek senior input for patients with complex issues such as those above to ensure appropriate fluids are prescribed.

Question 31

fluids in vomiting

Answer 31

As per the guidelines, this gentleman has evidence of hypovolaemia and therefore requires initial fluid resuscitation with a 500 ml bolus of either NaCl 0.9% or Hartmann’s solution.
Either would be appropriate, but given this gentleman has been vomiting and thus losing potassium, Hartmann’s is a better choice as it provides some potassium replacement.

Question 32

When is dextrose 5% given

Answer 32

Dextrose 5% in water is used to treat low blood sugar (hypoglycemia), insulin shock, or dehydration (fluid loss). Dextrose 5% in water is also given for nutritional support to patients who are unable to eat because of illness, injury, or other medical condition.