full drug log Flashcards
what is adrenaline
Adrenaline is a hormone and neurotransmitter, that is released in your bloodstream from the adrenal glands during sympathetic nervous system stimulation (fight or flight)
adrenaline presentation
Comes in an ampoule containing 1mg/1ml
adrenaline mechanism of action
Adrenaline stimulates alpha and beta receptors, primarily alpha 1, beta 1 and beta 2.
Alpha 1:
Smooth muscle contraction
Vasoconstriction of blood vessels
Stimulation of glycogenolysis (Glycogen → glucose) and gluconeogenesis (Glucose formation from carbs/sources)
Beta 1 causes an increase in:
Inotropy = cardiac contractility
Chronotropy = heart rate
Dromotropy = speed of electrical conduction of heart
Beta 2:
Smooth muscle relaxation
Skeletal muscle vasodilation
Bronchodilation
Stabilisation of mast cell membranes which reduces histamine release
adrenaline indications
Clinically significant epistaxis
Stridor causing moderate to severe respiratory distress
Anaphylaxis
Severe asthma
Clinically significant bleeding from a wound
ILS INDICATIONS
all of the above and adrenaline IV for cardiac arrest
OTHER IND
Imminent respiratory arrest from COPD
Severe bradycardia
BP support if unresponsive to metaraminol
Septic shock, cardiogenic shock, and neurogenic shock, unresponsive to 0.9% sodium chloride IV and metaraminol IV
adrenaline contraindications
nil
adrenaline cautions
Myocardial ischaemia - increases myocardial oxygen demand
Tachydysrhythmias - worsens this
adrenaline for epistaxis dosage
0.2 mg (2 mls) aged 12 and over
0.1 mg (1 mls) 5-11 years.
Repeat dose after 20 mins
adrenaline for stridor dosage
5mg undiluted
repeat after 10 minutes
adrenaline for asthma/anaphlaxsis
0.5 mg every 5-10 minutes as required
asthma Repeat adrenaline IM every ten minutes if the patient is deteriorating and adrenaline IV is not being administered.
anaphlaxsis Repeat the adrenaline IM every ten minutes if the patient is not improving, or every five minutes if the patient is deteriorating.
adrenaline from cardiac arrest
Adults and children weight over 50kg: administer 1 mg undiluted every 4 minutes
Pead: dilutes 1 mg adrenaline to 10 mls. 0.1mg/ml. Draw dose from the solution and administer as a bolus
adrenaline adverse effects
Hypertension, hyperglycaemia
Ectopy
Sweating
Ischaemia
Tachycardia / tachydysrhythmia
Anxiety
Nausea / vomiting
Tremor
IM onset of adrenaline
2-5 minutes
Iv onset of adrenaline
5-10 seconds
duration of adrenaline
The cardiovascular effects last 5-15 minutes.
The mast cell membrane effects may last for several hours.
amiodarone preparation
150mg in 3ml
what is amiodarone
class III anti-dysthymic with broad spectrum activity
mechanism of amiodoarone
Predominantly inhibits potassium channels particularly during phase 3 (rapid repolarization), prolonging action potentials
Partially inhibits calcium channels slowing AV node
Minor sodium + beta adrenergic blocking = decreased excitability and rate
indications of amiodarone
Cardiac arrest with VF or VT at any time after the first dose of adrenaline
ICP
Adults with sustained VT in the absence of cardiac arrest.
Adults with moderate cardiovascular compromise as a result of fast atrial fibrillation or fast atrial flutter.
contraindications of amiodarone
Known severe allergy
Known severe allergy to iodine.
VT secondary to cyclic antidepressant poisoning. In this setting amiodarone administration can be associated with severe worsening of shock, without resolution of the rhythm.
name some examples of tricyclic antidepressants
Amitriptyline
noratriptyline
imperamine
Clomipramine
cautions of amiodarone
NIL IN CARDIAC ARREST
- poor perfusion or signs of low cardiac output
- hypotension
- AF with sepsis
- sick sinus syndrome without pacemaker
- pervious SSS without internal pacemaker
- pregnancy
amiodarone in pregnancy?
not unless strong clinical indication
dosage of amiodarone in cardiac arrest
300 mg if in VT or VF
150mg if VT or VF persists
adverse effects of amiodarone
Hypotension.
Lightheadedness.
Bradydysrhythmia.
onset of amiodarone
5-10 minutes
duration of amiodarone
1-4 hours after a single dose
slowly realised into tissue, thus more given, longer half life
goal of treatment for amiodarone in AF
If the indication is atrial fibrillation causing moderate cardiovascular compromise, the goal of treatment is to control the ventricular rate and not to revert the rhythm to sinus rhythm, although treatment with amiodarone may result in reversion of the rhythm to sinus rhythm. If a patient has been in atrial fibrillation for longer than a few days, there is a small risk that this may be associated with emboli leaving the left atrium. This is why amiodarone is reserved for patients with cardiovascular compromise that is clinically significant.
what to do if patient reverts while amiodarone is being administered
If amiodarone is commenced, the full dose should be administered even if the rhythm reverts to sinus rhythm, unless severe hypotension or bradycardia occurs.
ECG changes with amiodarone
Amiodarone is often described as relatively contraindicated in the presence of a prolonged QT interval, but this only applies to long-term administration.
aspirin dosage
300mg tablets
what is aspirin
Also acetylsalicylic acid
→ An antiplatelet medicine which reduces the chance of forming blood clots
aspirin mechanism
It has antiplatelet (clot preventing), antipyretic (reduce fever), anti-inflammatory, and analgesic effects, and we use it for its antiplatelet effects
→It inhibits the enzyme cyclooxygenase which reduces the formation of prostaglandins and thromboxane
aspirin indications
myocardial ischemia
aspirin contraindications
allergy
third trimester of pregnancy
aspirin cautions
Known bleeding disorder. Aspirin will increase the risk of bleeding, however the balance of risk is usually in favour of administering aspirin.
Clinically significant bleeding. Aspirin will increase the risk of bleeding and the nature and risk of the bleeding must be taken into account.
Known worsening of bronchospasm with NSAIDs. Some patients with asthma or COPD have known worsening of bronchospasm with NSAIDs (including aspirin) and a decision must be made based on the balance of risk. If there is a clear history of significant bronchospasm with NSAIDs, aspirin should be withheld.
aspirin and pregnancy?
no
adverse effects of aspirin
increased bleeding
long term indigestion and GI ulceration
onset of aspirin
30-60 minutes
duration of aspirin
3-5 days
cefazolin preparation
1g powder
what is cefazolin
first generation cephalosporins
cefazolin mechanism
the AB’s binds to the penicillin binding protein
PBP function inhibited, thus cell walls of bacteria not built effectively
due to ineffective cell wall, the cell cannot withstand the osmotic pressure, thus ruptures, killing the bacterias cell
indication of cefazolin
Sepsis, where the source of infection appears to be the soft tissues or joint, and:
1.The patient is aged greater than or equal to 12 years, and
2. Has one or more clinical features indicating antibiotics, and
3. Time to hospital is greater than 30 minutes.
Cellulitis. In this setting a single dose may be administered if the patient is not being directly referred (or transported) to a medical facility.
compound fracture including skull fracture
large contaminated wounds
following chest decompression
following amputation
contraindications of cefazolin
allergy to cephalosporins
cautions of cephalosporins
nil
pregnancy and ABs?
safe and administer if indicated
admin of cefazolin
Add approximately 4 ml of 0.9% sodium chloride to a 1 g ampoule and shake until dissolved.
Draw up the ampoule contents and dilute to a total of 10 ml.
Administer IV over 1-2 minutes preferably into a running line.
adverse effects of cefaolin
nil
onset of cefazolin
30-60
duration of cefazolin
6-8 hours
rapid admin of cefazolin can cause
pain and phlebitis, which is why it should be preferably administered into a running line.
presentation of ceftriaxone
2g powder
what is Ceftriaxone
Ceftriaxone is a cephalosporin antibiotic with broad activity against gram-negative and gram-positive bacteria
ceftriaxone mechanism
the AB’s binds to the penicillin binding protein
PBP function inhibited, thus cell walls of bacteria not built effectively
due to ineffective cell wall, the cell cannot withstand the osmotic pressure, thus ruptures, killing the bacterial cell
ceftriaxone indications
Suspected meningococcal septicaemia.
Sepsis, where cefazolin is not indicated, and:
The patient is aged greater than or equal to 12 years,
One or more clinical features indicating antibiotics are present,
Time to hospital is greater than 30 minutes.
contraindications fo ceftriaxone
Anaphylaxis to cephalosporins.
cautions of ceftriaxone
nil
adverse effects of ceftriaxone
nil
onset of ceftrixone
30-60
duration of ceftriaxone
24 hours
preparation needed for ceftriaxone in context of meningococcal
As meningococcal bacteria die they release endotoxins. The body’s immune response to endotoxins can cause profound worsening of shock following antibiotic administration. Be prepared to treat this with 0.9% sodium chloride IV, and metaraminol or adrenaline IV. It is rare for significant amounts of endotoxins to be released from other bacteria.
droperidol preparation
2.5mg/1ml
what is droperidol
antipsychotic/ butyrophenone (D2 blocker)
mechanism of droperidol
The main actions seem to stem from its potent Dopamine(2) receptor blocker with minor antagonistic effects on alpha-1 adrenergic receptors as well, resulting inresulting in sedation, reduced agitation and a state of mental detachment, and antiemetic action.
-some minor GABA stimulation
indications of droperidol
Patients aged greater than or equal to 12 years with acute behavioural disturbance causing a mild to moderate risk to safety, when olanzapine has not been administered or is ineffective.
Moderate to severe pain associated with one of the following, despite opiate analgesia, and ketamine is not appropriate:
Chronic or complex pain.
Chronic use of opiates.
Severe headache.
Severe pain associated with agitation.
Pain associated with severe nausea and/or vomiting.
Management of agitation or pain that does not respond to an opiate during end of life care.
Nausea and/or vomiting that persists despite ondansetron, or where motion sickness is a component of the patient’s nausea and/or vomiting.
droperidol contraindications
Known severe allergy.
Aged less than 12 years.
Pregnancy (analgesia and nausea and/or vomiting only).
droperidol cautions
Altered level of consciousness. This will increase and prolong the effects.
🔶Parkinson’s disease. There is a risk of worsening the movement disorder associated with Parkinson’s disease.
🔶Concurrent administration of ketamine or midazolam. This will increase and prolong the effects.
🔶Aged greater than or equal to 75 years, particularly if frail. The effects of droperidol will be increased and prolonged in this cohort.
🔶Signs of shock. Droperidol may make shock worse due to its alpha receptor blocking properties
droperidol dose for analgesia
1.25 mg IV for an adult, once only. Consider reducing the dose to 0.625 mg IV if a caution is present. dilute to 4 mls, give 2 mls
droperidol doseage for ABD and repeat time
10 mg IV or IM.
Consider reducing the dose to 5 mg if a caution is present.
The dose may be repeated once after 20 minutes.
IV: Draw up the required dose into a 10 ml syringe and dilute to a total of 10 ml using 0.9% sodium chloride
droperidol for end of life care dosege
2.5 mg IV/IM/SC.
The dose may be repeated as required.
dorperidol dosage and draw up for nausea and vomiting
0.625 mg IV/IM for an adult, once only.
Draw up 2.5 mg into a 5 ml syringe and dilute to a total of 4 ml using 0.9% sodium chloride. This gives a 0.625 mg/ml solution.
adverse effects droperidol
hypotension (due to Alpha 1 antagonist)
onset of droperidol
IV/IM: 5-10 minutes.
duration of droperidol
4-6 hours
drug interactions of droperidol
Intoxication. Droperidol will have increased sedative effects if the patient is intoxicated with alcohol or has taken recreational drugs.
Sedative drugs. Concurrent administration with other sedative drugs (such as olanzapine or midazolam) will result in an increased sedative effect.
droperidol and QT interval
Droperidol has been reported to prolong the QT interval. This generally involved repeated and/or high doses and one or two doses are safe, even if the patient is known to have a prolonged QT interval.
What kind of pain is droperidol used for?
Droperidol has a role in reducing pain associated with chronic or complex pain, headache, and pain associated with clinically significant distress, nausea and/or vomiting.
What kind of movements can droperidol cause
Droperidol may cause dyskinesia (abnormal, uncoordinated and involuntary movements) but this is unusual following one or two doses.
preparation of fentanyl
100mcg/2mls
what is fentanyl
opioid receptor stimulation (mu receptors)
fentanyl mechanism
Fentanyl is a synthetic opioid agonist that binds to opioid receptors in the brain and spinal cord, producing its analgesic and sedative effects. The primary mechanism of action involves the activation of mu opioid receptors (MOR), which are the primary opioid receptors responsible for pain modulation
Opioid analgesics are believed to bind to mu receptors, one of three different types of opioid receptors.
fentanyl indications
Moderate to severe pain.
Cardiogenic pulmonary oedema with severe anxiety.
Rapid sequence intubation.
Sedation post intubation.
Control of pain, agitation, or shortness of breath during end of life car
fentanyl contrindications
known allergy
fentanyl cautions
- altrerd LOC
- Respiratory depression or at high risk of respiratory depression.
- signs of shock
- Concurrent administration of other opiates, ketamine or midazolam.
- labour
- Aged greater than or equal to 75 years, particularly if frail.
- Aged less than one year.
why is being less than one a caution for opioids
(Children under the age of one year are at increased risk of respiratory depression following opiate administration)
why is resp depression a caution for opioids
(Such patients may develop respiratory depression following opiate administration because it inhibits the neutrons from firing up the spinal cord into the medulla)
why is labour a caution for opioids
(Opiates cross the placenta and may cause drowsiness and/or respiratory depression in the baby, particularly when administered within an hour or two of birth. Discuss administration with the lead maternity carer if possible. Following birth, close observation of the baby is required and personnel must be prepared to treat respiratory depression)
IV dosage for fentanyl
IV for analgesia:
10-50 mcg every five minutes for an adult, as required. Use a dose at the lower end of the range if the patient is frail or has signs of shock.
IM fent doseage
IM and SC for analgesia if IV access cannot be obtained:
50-100 mcg IM/SC.
Subsequent doses may be administered every 20 minutes up to a total of three doses.
Halve all doses if the patient is frail or has signs of shock.
IV fent for 10kg 1 year old dose
2-10 mcg
fent adverse effects
Respiratory depression.
Bradycardia.
Hypotension.
Sedation.
Nausea and vomiting.
Itch.
Euphoria.
IV onset of fent
IV: 2-5 minutes. The maximal analgesic and respiratory depressant effects may not occur until 10-15 minutes and this may be longer in the elderly.
IM onset of fent
IM/SC: 5-10 minutes.
duration of fent
30-60 minutes.The effect on respiration may last for several hours.
common interactions of fent
The effects will be increased in the presence of other opiates and sedatives, for example, benzodiazepines or alcohol.
GTN presentation
0.4 mg sublingual spray
what is GTN
a vasodilator
mechanism of GTN
→ Acts on vascular smooth muscle, causing venous and arterial vasodilation, predominant effect on veins
→ MOA is not clear but appears that it forms nitric oxide which is a vasodilator
GTN causes:
Reduction in venous return (preload) and peripheral resistance (afterload) which reduces myocardial oxygen demand and blood pressure
Dilation of coronary arteries with increases coronary blood supply
GTN indications
Myocardial ischaemia
ACPO
Control of HTN for autonomic dysreflexia
Control of HTN prior to fibrinolysis for STEMI
Control of HTN during inter-hospital transfer for STEMI
GTN contradictions
Known severe allergy
SBP less than 100 mmHg
HR less than 40
HR above 150
VT
GTN cautions
STEMI, especially RV (
Frail patient
Signs of shock (CO may fall further with GTN)
Dysrhythmia (CO may fall further with GTN)
Phosphodiesterase in the last 24 hours
Known aortic or mitral stenosis (Narrowing of aortic or mitral valves)
examples of phospodiastrase
cialus, viagra
GTN admin for myocardial ishcemia
Myocardial ischaemia: 0.4 mg every 3-5 mins.
Increase dosing to 10 mins if any cautions
GTN admin for ACPO
ACPO 0.8 mg every 3-5 mins
if GTN is admisntered when a caution is present, Pt should be…..
Patient should be lying flat, IV access should be obtained, interval should be 10 mins and be ready to administer fluids if needed
GTN adverse effects
Hypotension
Flushing
Headache
Tachycardia
Light-headed
GTN onset
1-2 minutes
GTN duration
15-30 minutes
glucose sachet indications
Hypoglycaemia ( less than 3.5) provided the patient is conscious to be able to swallow safely
Hypoglycaemia in neonates
glucagon indications
Hypoglycaemia (<3.5mmol/L) when the patient cannot swallow and IV cannot be obtained
when should IV glucose be admisntered
Administer glucose IV if the patient has a significantly altered level of consciousness or cannot swallow safely:
dosage of IV glucose
100 ml of 10% glucose IV for an adult.
2 ml/kg of 10% glucose IV for a child.
presentation of ibuprofen
200mg tablet
what is ibuprofen
NSIAD
ibuprofen mechanism
Inhibits activity of prostaglandin synthetase, reducing prostaglandin production which reduces inflammation, pain and fever
ibuprofen indications
Mild to moderate pain, usually in combo with paracetamol
Moderate to severe pain, usually in combo with other meds
(Particularly useful for soft tissue pain musculoskeletal pain, and renal colic)
ibuprofen contraindications
Known severe allergy
Pregnancy
Presence of sepsis, dehydration, shock or clinically significant bleeding (Ibuprofen can worsen renal impairment and increase bleeding risk)
Known worsening of bronchospasm with NSAIDS
ibuprofen cautions
Taken within last four hours (Additional ibuprofen may be administered if the total dose in the last 4 hours does not exceed the CPG dose)
Abdo pain, particularly if unwell or vomiting (The possibility of significant intra-abdominal pathology exists and oral meds should usually be withheld)
Age greater than 75 years particularly if frail (Renal impairment is likely and ibuprofen worsens this)
ibuprofen dosage
600 mg over 80 kgs
→ 400 mgs over 80 kgs
presentation of paediatric ibuprofen
100mg/5 mls
adverse effects of ibuprofen
Renal impairment
Increased bleeding
Long term indigestion, GI ulceration and bleeding
onset of ibuprofen
30-60
duration of ibuprofen
4-6 Horus
presentation of ipatropium bromide
0.5 mg in 2mls
what is ipartopium
long acting bronchodilator
mechanism of ipatropium
→ Anticholinergic agent with antimuscarinic activity (As it acts on muscarinic receptors)
→ It antagonises acetylcholine receptors causing vagal inhibition resulting in bronchodilation
(Bronchoconstriction is driven by parasympathetic stimulation of the vagus nerve, so inhibiting the effects of the vagus nerve reduces this)
indications of ipatropium
Bronchospasm secondary to asthma or COPD
Prominent bronchospasm to airway burns, smoke inhalation or chest infection
contraindications of ipatropium
allergy
cautions of ipatropium
nil
adminstration of ipatropium
→0.5 mg undiluted nebulised adult and children
→ using oxygen as driving gas for asthma or medical air for COPD
No repeats
adverse effects of ipatropium
Tachycardia
Dry mouth
Blurred vision → repeated doses
onset of ipatropium
2-5 minutes
duration of ipatropium
4-6 hours
ketamine présentation
Ampoule containing 200 mg in 2 ml.
what is ketamine
Dissociative anaesthetic
ketamine mechanism
→NMDA Receptor Inhibition:
Blocks NMDA receptors, a subtype of glutamate receptors (excitatory neuron) involved in learning, memory, and synaptic plasticity.
Reduces glutamate release, leading to decreased neuronal excitation, analgesia, and sedation.
Disrupts neuronal communication, altering cognition, perception, and mood.
Dose-Dependent Effects:
Lower doses: Provide analgesia by reducing pain signal transmission.
Higher doses: Induce amnesia and dissociation (feelings of detachment).
Highest doses: Cause anaesthesia, leading to loss of consciousness and responsiveness
ILS ketamine indication
Severe pain that has not been adequately controlled with an opiate.
ICP ketamine inductions
inducing dissociation.
Acute behavioural disturbance causing a severe to immediately life-threatening risk to safety.
Rapid sequence intubation (RSI).
Significant movement during CPR that is interfering with resuscitation.
Asthma with severe agitation that is impairing the ability to safely provide treatment or transport.
ketamine contraindications
Allergy
Less than one
ketamine cautions
Altered level of consciousness. Ketamine may reduce the level of consciousness.
Signs of shock. Ketamine may make shock worse.
Current myocardial ischaemia. Ketamine may increase myocardial oxygen demand.
Concurrent administration of opiates or midazolam. This will increase and prolong the effects.
Aged greater than or equal to 75 years, particularly if frail. The effects of ketamine will be increased and prolonged in this cohort
ketamine IV dosage for analgesia
IV:0.25 mg/kg IV up to a maximum of 25 mg for an adult, administered over approximately 15 minutes. Repeat as required.
steps to draw up ketamine
Draw up 100mg/1lm ketamine into 1 mL syringe
Decant dose into 100ml glucose bag,so 100mg/100mls
Draw out dose
Give slowly over 15 mins
ketamine adverse effects
Transient hypertension.
Tachycardia.
Apnoea.
Nausea and vomiting.
Sedation.
Hallucinations.
IV ketamine onset
IV: 1-2 minutes
duration of ketamine
10-60 minutes.
what should be done prior to ketamine admin
Prior to administering ketamine for pain, sufficient opiates should be administered so that further doses are not providing additional analgesia. This will usually require 150-200 mcg of fentanyl or 15-20 mg of morphine for an adult.
management of hallucinations post ketamine admistertion
Do not treat hallucinations routinely with midazolam because the combination of midazolam and ketamine is commonly associated with a reduced level of consciousness, particularly if an opiate has also been administered. Most hallucinations will settle with a combination of explanation and time. However, midazolam in low doses may be administered IV if the hallucinations are severe provided the patient is obeying commands and physiologically stable.
how to calculate dosage of ketamine
Round the patient’s weight up to the nearest 10 kg when calculating doses.
lignocaine presentation
Ampoule containing 50 mg in 5 ml.
what is lignocaine
local anaesthetic
lignocaine mechanism
Lignocaine’s primary mechanism of action involves the blockade of voltage-gated sodium channels in nerve cells: leading to inhibition of nerve impulses and the movement of sodium ions, thus inhibiting the transmission of a pain signal
lignocaine inductions
Subcutaneous injection for prophylaxis of pain associated with IV cannulation.
Subcutaneous injection for digital ring blocks for analgesia when transport time is less than 60 minutes or ropivacaine is not available.
Intraosseous injection for significant bone pain associated with intraosseous administration.
contraindications of lignocaine
Known severe allergy
Local infection in the area of injection.
cautions of lignocaine
Taking an anticoagulant (ring block)
lignocaine and pregnancy?
safe, administer if indicated
lignocaine dose for ring block
administer approximately 1-2 ml of 1% lignocaine into the tissue on either side of the web space of the digit.
lignocaine max dose
The maximum subcutaneous dose for an adult is 200 mg (20 ml of 1% lignocaine). The subcutaneous dose may be repeated once after 30 minutes
IO lignocaine admin and dose
50 mg (5 ml of 1% lignocaine) for an adult.
The intraosseous dose may be repeated once after 15 minutes
administer slowly over 1-2 minutes and wait one further minute before infusing fluid. This is intended to limit the amount of lignocaine flushed into the circulation.
lignocaine adverse effects
stinging at site
onset of lignocaine
1-2 minutes for IV cannulation.
5-10 minutes for digital ring blocks.
duration of lignocaine
30-60 mins
lignocaine overdose presentation
Tingling around the mouth.
Seizures.
Dysrhythmias, particularly bradydysrhythmias.
Hypotension.
Cardiac arrest.
why is lignocaine cautioned if anti coagulated
it can impact clotting
doses causing ligncoine overdose
Overdose of lignocaine when administered subcutaneously is very rare, but can occur if doses exceed 3 mg/kg or more than 1 mg/kg is inadvertently administered IV. If this occurs the following may develop:
levetiracetam presentation
500mg in 5 mls
levetiracetam mechanism
Levetiracetam is an anticonvulsant. It is not clearly understood but is thought to inhibit seizure activity by;
blocking some calcium channels This reduces the influx of calcium ions into neurons, which can contribute to seizure activity.
binds to synaptic vesicle protein 2A, which is involved in the regulation of neurotransmitter release. This binding reduces the release of excitatory neurotransmitters, such as glutamate, and increases the release of inhibitory neurotransmitters, such as GABA.
what is levetiracetam
anticonvulsant
indication of levetiracetam
Seizure that continues or recurs after two doses of parenteral midazolam.
Seizure activity associated with TBI even if seizure activity has ceased post midazolam
levetiracetam contradictions
KDA
levetiracetam cautions
nil
levetiracetam and pregnancy?
safe and should be administered if indicated
levetiracetam dosage and admin
2g IV (20mls) diluted with 20-40 mls of saline, given over running line
adverse effects of levetiracetam
nil
onset of levetiracetam
10 minutes
duration of levetracitam
6-8 hours
loratadine presentation
10mg tablets
what is loratadine
non-sedative antihistamine
loratadine mechanism
Antagonises peripheral histamine receptors, blocking histamine and reducing itchiness/redness
loratadine indications
Minor allergic reaction confined to skin involvement
Prominent itch associated with anaphylaxis, provided all systemic signs have resolved
loratadine contraindications
Known severe allergy
Age less than 1 year
loratadine cautions
pregnancy
dosage of loratadine
→20 mg aged greater than 12
→ 10 mg aged 1-11
adverse effects of loratadine
nil
onset of loratadine
30-60 mins
duration of loratadine
12-24 hours
methoxy presentation
3mls
methoxy indication
Moderate to severe pain, especially when there is a delay in opiate admin
methoxy contradictions
Known severe allergy
Hx malignant hyperthermia (Inherited disorder of muscle metabolism, when exposed to anaesthetic agents the patient may develop a life-threatening hypermetabolic state with severe hyperthermia)
Renal impairment (Kidneys/ureter/urethra) (Dialysis pts, kidney stones and renal colic pts can have methoxy)
Administered in last week (Increase risk of renal impairment with frequent admin)
methoxy cautions
Age greater than 75, particularly if frail
Pre-eclampsia (Renal impairment is likely and methoxy will worsen this)
Confined space
dose of methoxy
→6 mls for patients aged above 12
→ 3 mls child aged less than 12
side effects of methoxy
Sedation
Light headed
metoprolol presentation
50mg tablets
what is metoprolol
beta blocker
metoprolol mechanism
Metoprolol is an immediate release beta blocker. It antagonises (blocks) beta-1 receptors in the heart, causing a decrease in heart rate, cardiac output and blood pressure.
metoprolol indications
Adults with mild or no cardiovascular compromise as a result of fast atrial fibrillation or atrial flutter.
Adults with moderate cardiovascular compromise as a result of fast atrial fibrillation or atrial flutter, if amiodarone is not available or is contraindicated
metoprolol contraindications
Known severe allergy.
Hypotension. Metoprolol will further reduce the blood pressure
metoprolol cautions
First degree heart block. Metoprolol may cause bradycardia.
Known sick sinus syndrome without an internal pacemaker in place. Metoprolol may cause bradycardia.
Previous second or third degree heart block without an internal pacemaker in place. Metoprolol may cause worsening of heart block and bradycardia.
Asthma or COPD. Metoprolol may cause bronchospasm and should usually be withheld if the patient regularly takes bronchodilators.
Heart failure. Metoprolol will reduce cardiac output and may make heart failure worse.
Pregnancy.
metoprolol and pregnancy
seek clinical advise
onset of metoprolol
10-20 mins
duration of metoprolol
4-6 hours
common interactions of metoprolol
The blood pressure effect will be potentiated by other medicines that lower blood pressure. For example, GTN, antihypertensive medicines and amiodarone.
The heart rate effects will be potentiated by other medicines that lower the heart rate. For example, amiodarone and centrally acting calcium channel blockers such as diltiazem.
should metoprolol be used if pt already beta blocked
Patients with chronic or paroxysmal atrial fibrillation/atrial flutter may be prescribed a beta blocker. Personnel should still administer metoprolol as indicated, even if the patient has taken their own beta blocker
midazolam preperation
→ 15mg/3mls
what is midazolam
benzodiazepine
mechanism of midazolam
Midazolam binds to the GABA-A receptor, increasing GABA’s affinity for the receptor.
This allows more GABA molecules to bind to the receptor.
Enhanced GABA binding leads to a stronger receptor response.
This increases chloride ion influx into the neuron.
The increased chloride ion influx has a calming effect, reducing the cell’s likelihood of firing.
By lowering neuron excitability, midazolam reduces the chance of dysregulated firing patterns.
indications of Midazolam
ILS
Generalised seizures that continue for more than five minutes, or seizures are recurrent.
Acute behavioural disturbance causing a mild to moderate risk to safety and droperidol is unavailable or ineffective.
ICP
Pain associated with severe muscle spasm or severe anxiety if adequate analgesia is not being achieved with an opiate and ketamine is not appropriate.
Sedation, for example, for joint relocation.
Sedation post intubation.
Severe anxiety associated with COPD.
Control of anxiety or shortness of breath that does not respond to an opiate during end of life care.
midazolam contridication
Known severe allergy
Aged less than 12 years (analgesia only).
midaz cautions
Altered level of consciousness. Midazolam will further reduce the level of consciousness.
Respiratory depression or at high risk of respiratory depression. For example, severe COPD, morbid obesity or on home BiPAP. Such patients may develop respiratory depression following midazolam administration.
Signs of shock. Midazolam may worsen shock.
Concurrent administration of opiates or ketamine.
This will increase and prolong the effects.
Aged greater than or equal to 75 years, particularly if frail. The effects of midazolam will be increased and prolonged in this cohort
pregnancy and Midazolam
Yes, if indicated (safety not proven)
IV midaz for seizure dosage
→Administer midazolam IV:
a) 5 mg of midazolam IV for an adult. Reduce the dose to 3 mg if the patient is frail.
c) This may be repeated once after five minutes.
IM midaz for seizure dosage
) 10 mg of midazolam IM for an adult. Reduce the dose to 5 mg if the patient is frail.
c) This may be repeated once after ten minutes
paediatric dose of midaz
10 kg / 1 year old
Midazolam IM (seizures)
2 mg
0.4 ml (undiluted)
IV midaz for ABD dose
IV 2-3mg in 5 minute intervals
IM midazolam of ABD dose
10mg IM, 20 minutes intervals
adverse effects of midazolam
Sedation.
Respiratory depression.
Hypotension.
Amnesia.
onset of midazolam
IV: 2-3 minutes.
IM: 3-5 minutes
duration of midaz
30-60 minutes. The sedative effect may be longer, particularly in the elderly.
morphine presentation
Ampoule containing 10 mg in 1 ml.
what is morphine
opioid analgesic
morphine MOA
binds to opiate receptors (stimulates them) causing analgesia
( fent/morph binds to opioid receptor stimulating G protein, G protein flicks a switch, to stop calcium going into the cell stopping it from becoming positive, thus inhibiting from sending signals, G protein opens potassium channels, letting positive change out of the cell, further inhibiting signal)
morphine indications
Moderate to severe pain.
Cardiogenic pulmonary oedema with severe anxiety.
Control of pain, agitation, or shortness of breath during end of life care.
morphine contriadicaitons
Known severe allergy
Renal failure on ant dialysis
morphine cautions
Altered level of consciousness. Morphine may further reduce the level of consciousness.
Aged less than one year. Children under the age of one year are at increased risk of respiratory depression following opiate administration.
Respiratory depression or at high risk of respiratory depression.
Labour. Opiates cross the placenta and may cause drowsiness and/or respiratory depression in the baby, particularly when administered within an hour or two of birth. \
Concurrent administration of other opiates, ketamine or midazolam. This will increase and prolong the effects.\
Aged greater than or equal to 75 years, particularly if frail. The effects of morphine will be increased and prolonged in this cohort.
Signs of shock. Morphine may worsen shock.
morphine and pregnancy
give if needed
IV morphine dosage analgesia
IV for analgesia:
1-5 mg every five minutes for an adult as required. Use a dose at the lower end of the range if the patient is frail or has signs of shock.
IV morphine for ACPO dosage
IV or morphine in 1-2 mg doses IV may be administered every five minutes as required for severe anxiety.
IM morphine dosage
5-10 mg IM/SC.
Subsequent doses may be administered every 20 minutes up to a total of three doses.
Halve all doses if the patient is frail or has signs of shock.
morphine side effects
Respiratory depression.
Hypotension.
Sedation.
Nausea and vomiting.
Histamine release and itch.
IV onset morphine
IV: 2-5 minutes. The maximal analgesic and respiratory depressant effects may not occur until 10-15 minutes and this may be longer in the elderly.
IM onset of morphine
IM/SC: 5-10 minutes.
duration of morphine
30-60 minutes.The effect on respiration may last for several hours, particularly in the elderly.
Morphine is usually the preferred opiate if
the patient requires analgesia for a longer period of time, or the patient is receiving end of life care.
why are opioids used in ACPO
Fentanyl is used in patients with acute cardiogenic pulmonary edema (ACPO) to provide anxiolysis and sedation, helping to reduce anxiety and distress while promoting hemodynamic stability and bronchodilation. Its rapid onset of action, short duration of action, and convenience of administration make it a valuable tool in managing symptoms and improving patient comfort in this critical care setting.
difference between morphine and fent
Receptor Binding: Morphine binds to mu, kappa, and delta opioid receptors, while fentanyl is more selective for mu receptors.
Potency & Duration: Fentanyl is more potent but shorter-acting, while morphine requires higher doses and lasts longer.
Metabolism: Morphine has active metabolites excreted by the kidneys, whereas fentanyl’s inactive metabolites reduce kidney-related risks.
naloxone presentation
Ampoule containing 0.4 mg in 1 ml.
what is naloxone
opiate receptor antagonist (blocker)
naloxone mechanism
Naloxone is an opiate receptor antagonist (blocker). By blocking opiate receptors, naloxone reverses the effects of opiates, particularly respiratory depression and sedation.
naloxone indications
Opiate poisoning is suspected and the patient has a significantly impaired level of consciousness or significantly impaired breathing.
Excess adverse effects from administration of opiates.
naloxone contradictions
KSA
naloxone cautions
Chronic opiate use. If the patient is taking an opiate chronically, there is a risk of adverse physiological effects associated with rapid opiate withdrawal.
naloxone and pregnancy
safety not proven but give if indicated
dosage of naloxone
→0.1-0.4 mg IV every five minutes as required for an adult.
0.8 mg IM as required for an adult. This may be repeated every 10 minutes.
how to draw up naloxone
IV: dilute 0.4 mg to a total of 4 ml. This final solution contains 0.1 mg/ml.
Administer the minimum dose required to produce improvement. Rapid reversal of opiates may be associated with seizures, hypertension, pulmonary oedema or severe agitation, particularly if the patient takes opiates regularly.
IM IS UNDILUTED
naloxone adverse effects
Sweating.
Tachycardia.
Hypertension.
IM AND IV onset of naloxone
IV: 1-2 minutes.
IM: 5-10 minutes.
duration of nalaxone
30-60 minutes.
The duration of action of naloxone may be shorter than the duration of action of the opiate that has been administered/taken and naloxone may need to be repeated.
role of nolaxone in cardiac arrest
There is no role for naloxone in the treatment of cardiac arrest associated with opiate poisoning. In this setting cardiac arrest is secondary to respiratory arrest and once cardiac arrest has occurred naloxone has no useful effect. The best treatment is CPR that includes a focus on ventilation. If ROSC occurs, naloxone should still not be administered because it may be associated with seizures, hypertension, pulmonary oedema or severe agitation.
oxygen admin in nalaxone
There is no evidence to support the commonly held view that adequate oxygenation prior to naloxone administration reduces the severity of agitation following naloxone administration. However, treatment of severe hypoxia takes precedence over the administration of naloxone.
withdrawals and agitation in naloxone
Acute opiate withdrawal following naloxone administration can lead to patient agitation and/or aggression, particularly when there has also been a period of hypoxia. Ensure a planned team approach to maintain safety of both the patient and personnel.
olanzapine presentation
5mg PO
what is olanzapine
atypical antipsychotic (2nd generation)
olanzapine mechanism
Olanzapine has actions at multiple receptors within the brain, such as inhibiting dopamine and serotonin receptors, causing a reduction in agitation, sedation, anti-anxiety and stabilisation of mood
olanzapine indications
Patients aged greater than or equal to 12 years with acute behavioural disturbance causing a mild to moderate risk to safety, when the patient will take an oral medicine
olanzapine contradictions
Known severe allergy.
Poisoning with an antipsychotic, for example quetiapine, risperidone or olanzapine.
olanzapine cautions
Pregnancy.
Intoxication. This will increase and prolong the effects.
Aged greater than or equal to 75 years, particularly if frail. The effects of olanzapine will be increased and prolonged in this cohort.
olanzapine dosage
10 mg PO.
Consider reducing the dose to 5 mg PO if a caution is present.
The dose may be repeated once after 20 minutes.
olazapine adverse effects
sedation
olanzpine onset
10-20 minutes
olanzpaine duration
12-24 hours
olanzapine common interactions
Intoxication. Olanzapine will have increased and prolonged effects if the patient is intoxicated with alcohol or has taken recreational drugs.
Sedative drugs. Concurrent administration with other sedative drugs (such as midazolam or droperidol) will result in an increased and prolonged effect.
preparation of ondansetron
→ 4 mg in 2 mls
what is ondansetron
antiemetic
ondansetron mechanism
Blocks serotonin receptors centrally in the brain (chemoreceptor trigger zone) and peripherally in the GI tract, reducing nausea and vomiting
(Serotonin receptors can effect nausea, and when in the GI tract can induce vomiting)
contradictions of ondansetron
Known severe allergy
Age less than 1 year
suspected serationin syndrome
what kind of medications causes serotonin syndrome
SSRI like citalopram, sertraline, fluoxetine
oxytocin preparation
10 units
what is oxytocin
→ Oxytocin is a synthetic version of the naturally occurring hormone oxytocin which is normally released from the pituitary gland.
oxytocin mechanism
→ Oxytocin stimulates oxytocin receptors on the uterus, causing an influx of calcium, triggering a positive feedback loop strengthening the contraction of the uterus and stimulating the production of endogenous oxytocin, increasing contraction and reducing the risk of PPH.
oxytocin indications
Following normal birth
Postpartum haemorrhage
oxytocin contraidcations
allergy
oxytocin cautions
nil
oxytocin for normal birth
Administer IM undiluted. The preferred site is the lateral thigh as this has the best absorption. If this site is not suitable use the lateral upper arm.
oxytocin for PPH
If oxytocin has already been administered as part of routine treatment following normal birth, an additional 10 units of oxytocin should be administered (in the other thigh) if postpartum haemorrhage develops. This may require meeting another vehicle.
adverse effects of oxytocin
Abdominal cramping.
Tachycardia.
Flushing.
onset of oxytocin
5-10 minutes
duration of oxytocin
30-60 mites
oxytocin and QT interval
Oxytocin has been reported to cause prolongation of the QT interval if the patient is taking other medicines that also prolong the QT interval. However, this is usually associated with prolonged IV infusions and is not a clinically significant consideration when administering one or two IM doses.
when would oxytocin be administered IV
Oxytocin must not be administered IV unless instructed to do so by a lead maternity carer or a doctor via the Clinical Desk.
paracetamol cautions
Patient taken paracetamol within last 4 hours
Abdo pain, particularly if pt is unwell or vomiting. (The possibility of significant intra-abdominal pathology exists and oral medicines should usually be withheld)
Known severe liver disease (Liver disease must be severely impaired before paracetamol clearance is altered, but usually withhold)
mechanism of prednisone
→ Corticosteroid with anti-inflammatory and immunosuppressive actions.
→ Inhibits production of inflammatory mediators, prostaglandins and leukotrienes, reducing inflammatory and immune response.
indication of prednisone
Bronchospasm associated with asthma or COPD
Croup
Minor allergy associated with rash
prednisone cautions
Age less than 5 with asthma (Steroids do not usually have a role as they do not generally alter the course of their asthma exacerbation)
Ticagrelor presentation
90 mg PO tablet
what is ticagrelor
antiplatlet
ticagrelor mech
Ticagrelor works by producing a reversible inhibition of the ADP (adenosine diphosphate) receptor on platelets. ADP is a chemical that binds to receptors on platelets, causing them to aggregate and form clots. By inhibiting the ADP receptor, ticagrelor reduces the ability of platelets to respond to ADP and aggregate.
ticagrelor indications
STEMI, in conjunction with the primary PCI pathway, when requested by the accepting clinician.
ticagrelor contraidications
Known severe allergy
ticegralor cautions
Clinically significant bleeding. Ticagrelor will increase bleeding.
At risk of bleeding.
Pregnancy.
Ticagrelor and pregnancy?
not proven, seek clinical advise
ticagrelor doseage
180mg PO for an adult
Ticagrelor side effects
Increased bleeding
ticagrelor onset
30-60 minutes
ticagrelor duration
24 hours
Why do we want to inhibit ADP in the context of a STEMI?
ADP catalyses the aggregation of platelets, thus increasing the size of the thrombus. As platelets accumulate, they release chemicals that in turn attract more platelets in a positive feedback loop. thus, inhibiting ADP, inhibits this feedback loop.
tramadol presentation
50mg tablets
what is tramadol
analgesic
tramadol mechanism
→ Multiple actions in central nervous system, including opiate receptor stimulation and inhibition of the reuptake of noradrenaline and serotonin
tramadol indications
Moderate to severe pain, particularly if an opiate / ketamine is not going to be administered
tramadol contraindications
Known severe allergy
Age less than 12
tramadol cautions
Taken within last 4 hours (Additional can be given if it is clear the total dose within the last 4 hours does not exceed the dose in CPGs)
Abdo pain, particularly if unwell or vomiting (Possibility of significant intra-abdominal pathology exists and oral meds should usually be withheld)
Age greater than 75, particularly if previous history of dementia or confusion (Tramadol has anticholinergic activity and may worsen confusion)
Confusion (Tramadol has anticholinergic activity and may worsen confusion)
Pregnancy
tramadol side effects
Nausea or vomiting
Light headed or unusual
Sedation
Dry mouth
TXA presentation
10 ml ampoule containing 1 g OR 5 ml ampoule containing 500 mg.
what is TXA
→Tranexamic acid is an antifibrinolytic medicine
TXA mechanism
→ It blocks the conversion of plasminogen to plasmin, reducing fibrinolysis (breakdown of blood clots) and bleeding.
TXA indications
Postpartum haemorrhage.
Clinically significant bleeding or signs of hypovolaemia following trauma. Non-traumatic bleeding and shock is severe.
Cardiac arrest secondary to trauma.
Bleeding following tonsillectomy.
Crush injury.
TXA contraindications
Known severe allergy
Trauma when tranexamic acid will be administered more than three hours after the time of injury.
TXA cautions
nil
TXA and pregnancy
safety not proven, given if needed
dose of TXA for adult cardiac arrest secondary to trauma, bleeding from trauma & crush injury
2 g IV for an adult cardiac arrest secondary to trauma, bleeding from trauma & crush injury
difference between cefazolin and ceftriaxone
In summary, while both antibiotics are used to treat bacterial infections, cefazolin is more effective against Gram-positive bacteria and is often used for skin and soft tissue infections, whereas ceftriaxone has a broader spectrum of activity and is commonly used for more severe infections, including meningitis and sepsis.
TXA for non traumatic bleeds
1g non traumatic bleeding
TXA tonsillectomy bleed dosage
500mg nebulised and 1g IV for tonsillectomy bleeding
TXA adverse effects
nil
TXA onset
30-60 mins
TXA duration
8 hours
salbutamol ind
Bronchospasm secondary to asthma or COPD.
Prominent bronchospasm secondary to airway burns, smoke inhalation or chest infection.
Release syndrome following crush injury.
Known or suspected hyperkalaemia with ECG changes.
salbutamol contras
KSA
salbutamol cautions
nil
salbutamol side effects
tachy
tremor
salbutamol onset and duration
2-5 mins
1-2 hours
