Intermediate Flashcards
Adrenaline intro
Presentation:
1 mg/1 mL (1:1000) ampoule
- A naturally occurring sympathomimetic agent
- Causes peripheral vasoconstriction
- Stimulation of cardiac conduction system causes increased contractions
- Causes bronchodilation and dilation of blood vessels in muscles
IV/IO: Onset 30 seconds, half-life 5 minutes, duration 5-10 minutes
IM: Onset 60 seconds, half-life 5 minutes, duration 5-10 minutes
Adrenaline Indications
- Severe croup
- Post ROSC
- Anaphylaxis
- Life threatening asthma
- Cardiac arrest
Adrenaline Contraindications
There are no absolute contraindications to Adrenaline.
Adrenaline Special Considerations
- Pupil dilation
- Hypertension
- Anxiety
- Tremors
- Tachyarrhythmias, palpitations
Amiodarone Intro
- Amiodarone is a Class III antidysrhythmic agent that prolongs the action potential duration and hence the refractory period of atrial, nodal and ventricular tissue, thereby giving a very broad spectrum of activity.
- Immediate onset, peak <10min, duration 30-60mins
Amiodarone Indications
Cardiac Arrest with persistent/shock resistant Ventricular Fibrillation/Pulseless Ventricular Tachycardia, post 3rd shock (ANZCOR 2016).
Amiodarone Contraindications
- No contraindications in cardiac arrest.
- Not compatible with saline (If infusion dose is advocated by a specifically authorised person).
Amiodarone Special Considerations
- Bradycardia
- Hypotension
- Polymorphic tachycardia’s
- Nausea
- Tremor
- Dizziness
- Paraesthesia
- Headaches
- Phlebitis
Aspirin Intro
Aspirin has the following pharmacological actions:
- Anti-pyretic
- Anti-platelet aggregate
- Analgeisic
-Anti-inflammatory
Reduces mortality significantly in Acute Myocardial Infarction by minimising platelet aggregation and thrombus formation in order to retard the progression of coronary artery thrombosis
Aspirin Indications
- Patients with suspected Acute Coronary Syndromes.
Aspirin Contraindications
- Known hypersensitivity to aspirin / salicylates / NSAIDs.
- Children < 16 years of age.
Aspirin Special Considerations
- Heart burn, nausea, GI bleeding.
- Increased bleeding time.
- Anaphylactic reaction (some patients, especially asthmatics) exhibit notable sensitivity to aspirin, which may provoke various hypersensitivity / allergic reactions.
Atropine Intro
- An anticholinergic agent that inhibits the action of acetylcholine on post ganglionic nerves at the neuroeffector site. This blocks vagal stimulation to allow the sympathetic response to increase pulse rate by increasing SA node firing rate, and increasing the conduction velocity through the AV node.
- An antidote to reverse the effects of cholinesterase inhibitors such as seen with organophosphate poisoning.
Atropine Indications
- Symptomatic Bradycardia, haemodynamically unstable due to the bradycardia and associated with poor signs of perfusion, including:
- Hypotension
- Altered conscious state
- Diaphoresis
- Shortness of breath, and/or cyanosis
- Syncope
- Organophosphate poisoning with cholinergic effects
Atropine Contraindications
- Known Hypersensitivity
- Patients with cardiac transplant.
Atropine Special Considerations
- Confusion, restlessness (large doses)
- Hot, dry skin (large doses)
- Dilated pupils and/or blurred vision
- Dry mouth and/or urinary retention
- Tachycardia and/or palpitations
Cophenylcaine Intro
Pump spray containing:
- Lidocaine (lignocaine) hydrochloride monohydrate 5%, 5 mg/spray
- Phenylephrine hydrochloride 0.5%, 500 microg/spray
- A topical local anaesthetic and haemorrhage control agent for the relief of surface pain, nasal and oral bleeding.
Cophenylcaine Indications
- Local pain: abrasions, small cuts and wounds
- Relief of mild and moderate epistaxis
- Post tonsillectomy haemorrhage
- Intra-oral haemorrhage
Cophenylcaine Contraindications
- Hypersensitivity to phenylephrine, lidocaine or other anaesthetics
- Children <2yrs
- Pregnancy
Cophenylcaine Special Considerations
- Oral administration may cause a transient bitter taste
Droperidol Intro
- Droperidol is a neuroleptic, antipsychotic agent that acts on Alpha and Dopamine receptors, resulting in sedation
- Onset of effect usually 3-5 mins both IM and IV
- Use of a sedative agent should never be considered routine. Have a high threshold to offer or administer.
Droperidol Indications
- Disturbed and Abnormal Behaviour (RASS 1 ~ 3) if considered appropriate where risk to safety is evident and de-escalation has not been effective.
- Dementia and frail patients where Olanzapine cannot be administered or is ineffective.
Droperidol Contraindications
- Known allergy
- Known Parkinson’s Disease
- Where Ketamine has been administered to sedate this episode
- Age < 6 years old
- Post-ictal Disturbed & Abnormal Behaviour
Droperidol Special Considerations
- Extrapyramidal effects / Dyskinesia
- Increased falls risk
- Hypotension
- Apply monitoring as soon as practicable
Fentanyl Introduction
A short acting synthetic narcotic analgesic.
- Fentanyl: 450 microg/1.5 mL (300 microg/mL); intra-nasal administration only
- Fentanyl Citrate: 100 microg/2 mL ampoule (50 microg/mL); IV/IO only
- Fentanyl Citrate: 500 microg/10 mL ampoule (50 microg/mL); IV/IO only
Fentanyl Indications
- Moderate to severe pain.
- Acute Coronary Syndromes where GTN has been ineffective.
Fentanyl Contraindications
- Hypersensitivity to fentanyl
- Child <1 year of age (for IV / IO only)
- Occluded nasal passages or epistaxis (for IN only)
Fentanyl Special Considerations
- Adopt a low threshold to engage with the ED team if pain remains difficult to control
- Drowsiness
- Nausea/vomiting
- Respiratory depression; monitor pulse oximetry for all patients having IV / IN Fentanyl
- Cardiovascular effects:
- Bradycardia
- Hypotension (rare)
Glucagon Intro
- A hyperglycaemic agent that increases blood glucose concentration by activating hepatic glucose production and decreasing GI motility
- Onset: 4-7 minutes; duration 10-40 minutes
Glucagon Indications
- For demonstrated hypoglycaemia where oral glucose cannot be administered and IV access cannot be obtained in a safe and timely manner.
- Altered conscious state in a known diabetic or of otherwise unknown cause where blood glucose level is below 4mmol/L.
Glucagon Contraindications
- Known hypersensitivity
- Known pheochromacytoma, insulinoma, glucagonoma
Glucagon Special Considerations
- Nausea/vomiting
- Gastric pain
- Transient rise of blood pressure for patients taking beta blockers.
Glucose 10% IV Intro
- A hypertonic crystalloid solution that provides a readily available source of energy (glucose)
- Onset within 1 minute
- Contains 100 mg glucose anhydrous/ml
Glucose 10% IV Indications
Demonstrated hypoglycaemia where oral glucose administration is inappropriate in:
- Altered conscious state in known diabetic or of otherwise unknown cause where blood glucose level is below 4 mmol/L.
- Cardiac arrest, only if hypoglycaemia is suspected as a contributory cause of the arrest, not an early indication.
Glucose 10% IV Contraindications
- Not be used if there is no patent IV access
Glucose 10% Special Considerations
- Hyperglycaemia
- Diuresis
- Thrombophlebitis
- Tissue necrosis
Glucose Oral Gel Intro
- Rapidly absorbed from oral/buccal mucosa to increase blood glucose concentration
- Onset 2-5 minutes; duration 12-25 minutes
- Contains 15 g glucose
Glucose Oral Gel Indications
Demonstrated hypoglycaemia in:
- Altered conscious state in a known diabetic.
- Altered conscious state of unknown medical cause, where blood glucose level is below 4 mmol/L.
Glucose Oral Gel Contraindications
- Nil
Glucose Oral Gel Special Considerations
- Airway obstruction
GTN Intro
Nitrates cause the relaxation of vascular smooth muscle resulting in:
- Vasodilation
- Peripheral pooling and reduced venous return
- Reduced left ventricular end diastolic pressure (preload)
- Reduced systemic vascular resistance (afterload)
- Reduced myocardial energy and oxygen requirements
- Relaxes spasm of coronary arteries
Also known as nitroglycerin
GTN Indications
- Chest pain/discomfort of presumed cardiac origin not relieved by rest and reassurance with systolic BP > 90 mmHg where the heart rate is within 50-150 beats per minute.
- Acute Cardiac Pulmonary Oedema with systolic BP >90 mmHg.
- Autonomic Dysreflexia with systolic BP > 160 mmHg.
GTN Contraindications
- Hypersensitivity
- Hypotension < 90 mmHg
- Ventricular Tachycardia (VT)
- Recent use of medications used for erectile dysfunction:
Sildenafil (Viagra®) or Vardenafil (Levitra®) or Avanafil (Spedra®) use in the previous 24 hours
Tadalafil (Cialis®) use in the previous 3 days
GTN Special Considerations
Side effects:
- Hypotension (rare)
- Tachycardia
- Flushing
- Headache
- Dizziness
Heparin Intro
- A naturally occurring anticoagulant which inhibits the clotting of blood by enhancing the rate at which antithrombin III neutralises thrombin and activated factor X (Xa).
- Onset of action is immediate following IV administration.
Heparin Indications
- Patients with STEMI going directly to Cardiac Catheterisation Laboratory as per receiving hospital 12-lead ECG interpretation.
Heparin Contraindications
- Hypersensitivity to heparin
- Active bleeding (excluding menses) or disease states with an increased risk of bleeding (e.g. haemophilia)
Heparin Special Considerations
- Haemorrhage
- Hyperkalaemia
- Thrombocytopenia
Hydrocortisone Intro
- Hydrocortisone is an adrenocortical steroid that produces an anti-inflammatory process. This inhibits the accumulation of inflammatory cells at inflammation sites, phagocytosis, lysosomal enzyme release and synthesis and/or release of mediators of inflammation. Additionally, it prevents and suppresses cell mediated immune reactions.
Hydrocortisone Indications
- Patients with known adrenal insufficiency who are symptomatic of adrenal crisis
Hydrocortisone Contraindications
- Known hypersensitivity
Hydrocortisone Special Considerations
- Tachycardia
Normal Saline Intro
- A sterile isotonic crystalloid solution
Normal Saline Indications
- Fluid replacement (volume expansion) for the treatment of shock, fluid loss, and cardiac arrest.
Normal Saline Contraindications
- Severe pulmonary oedema
Normal Saline Special Considerations
- Hypervolaemia
Ipratropium Bromide Intro
- An anticholinergic bronchodilator. It inhibits the vagal reflexes that mediate bronchospasm
- Combined with a nebulised short-acting beta-2 agonist (e.g. salbutamol), ipratropium bromide produces significantly greater bronchodilation than a short-acting beta-2 agonist alone
Ipratropium Bromide Indications
Severe bronchospasm:
Adult:
- Severe to life-threatening asthma or COPD
Paediatric:
- Severe to life-threatening asthma
Ipratropium Bromide Contraindications
- Hypersensitivity
Ipratropium Bromide Special Considerations
- Headache
- Nausea, dizziness
- Dry mouth, throat irritation
- Taste disturbance
- Skin rash
ketamine Intro
- Rapid acting dissociative anaesthetic
- IM onset: 5-10 minutes
- IV onset: 1 minute
- Use of a sedative agent should never be considered routine. Have a high threshold to offer or administer.
Ketamine Indications
- IV: Second line agent for severe pain of traumatic origin post IV Fentanyl administration. ASMA consult needed if IV Fentanyl minimum dose (age
dependent as per CPG) has not been given prior to IV Ketamine administration - IM: First line agent for severe pain of traumatic origin should other means of administering pain medication not be available
- Combative Traumatic Brain Injury
Paramedic only:
- (RASS 4) First line agent for severely disturbed or abnormal behaviour where there is an immediate risk to safety and rapid tranquilisation is required and no other sedative medications have already been administered to this patient
Ketamine Contraindications
- Hypersensitivity
- Active cardiovascular disease including cardiac chest pain, heart failure, severe or poorly controlled hypertension
- Patients with delayed transfer of care (i.e. ‘ramped’)
- Disturbed and abnormal behaviour that are clearly not RASS 4 or where other sedative agents have already been administered (ASMA authority required)
- Rapid Tranquillisation ONLY: Age < 16 years old
- Age < 1 years old
Ketamine Special Considerations
- Blood pressure and pulse frequently elevated
- Random purposeless movements, muscle twitching and rash are common
- Hypersalivation
- Emergence reactions (10%)
- Transient laryngospasm
- Transient apnoea or respiratory depression
Lignocaine 1% Intro
- Reversibly interrupt impulse conduction in peripheral nerves and stabilise excitable cell membranes by blocking Sodium Channels
- Onset 1-2 minutes
Lignocaine 1% Contraindications
- Hypersensitivity
Lignocaine 1% Special Considerations
- Tinnitus, dizziness, anxiety, confusion, perioral numbness
- Cardiovascular effects: Bradycardia, hypotension, dysrhythmias
- CNS effects
- Respiratory depression
Methoxyflurane Intro
- A halogenated ether that produces powerful modification of the awareness of pain with an associated light headed sensation.
- 6-8 breaths/ 1-2 min onset with maximum level after 2-4 minutes.
Methoxyflurane Indications
- Pain
Methoxyflurane Contraindications
- Patients who are unable to understand or co-operate.
- Patients with severe renal impairment.
- Patients with head injury and altered consciousness that prevents co-operation with its use.
- Hypersensitivity e.g. malignant hyperthermia
Midazolam Intro
- A water-soluble benzodiazepine that has anxiolytic, sedative and anticonvulsive characteristics. This is due to its bonding with receptors in the CNS; its action to increase the inhibitory effect of the g-aminobutyric acid (GABA) neurotransmitter on the GABA receptors and subsequent membrane threshold.
- Midazolam is lipid-soluble in physiological pH and it reaches the CNS quickly.
- Use of a sedative agent should never be considered routine. Have a high threshold to offer or administer.
Midazolam Indications
- Prolonged seizure activity - generalised seizure lasting ≥ 5 minutes OR recurrent / status seizure activity as per CPG
- Focal seizure activity which is prolonged (≥ 5 minutes) and is associated with a GCS ≤ 12 as per CPG
- Second-line IV agent for maintenance of sedation after Droperidol administration for Disturbed and/or Abnormal Behaviour
Midazolam Contraindications
- Hypersensitivity
- Use of Midazolam for sedation after Ketamine requires ASMA authority
Midazolam Special Considerations
- Respiratory depression
- Hypotension
- Anterograde and retrograde amnesia
- Myasthenia Gravis
Naloxone Intro
- Naloxone is a pure opioid antagonist that exerts its effect by competitive inhibition at the opioid receptor sites. It prevents or reverses the effects of opioids, including respiratory depression, sedation and hypotension. In the absence of opioids, it exhibits essentially no pharmacological activity.
Naloxone Indications
- Reversal of respiratory depression in a suspected narcotic overdose.
Naloxone Contraindications
- Hypersensitivity to Naloxone
Naloxone Special Considerations
Withdrawal symptoms such as:
- Aggression
- Agitation
- Nausea/vomiting
- Dilated pupils and lacrimation
Olanzapine Intro
- Olanzapine is a second generation antipsychotic agent that acts on multiple receptors (incl. serotonin and dopamine receptors), resulting in sedation
- Onset of effect usually ~ 10 mins.
Use of a sedative agent should never be considered routine. Have a high threshold to offer or administer.
Olanzapine Indications
- Disturbed and Abnormal Behaviour (RASS 1 ~ 3) if considered appropriate where risk to safety is evident and de-escalation has not been effective
- Patient is able to tolerate or self-administer an oral wafer
- Preferred first line sedation agent in frail patients and those with Dementia
Olanzapine Contraindications
- Known Allergy
- Known Parkinsons Disease
- Age < 6 years old
Olanzapine Special Considerations
- Extrapyramidal effects / Dyskinesia
- Increased falls risk
- Hypotension – Apply monitoring as soon as practicable
Ondansetron Intro
- Anti-nauseant and anti-emetic
- Selective 5-HT3 receptor antagonist blocking serotonin centrally in the chemoreceptor trigger zone and peripherally on Vagus nerve terminals.
- Onset of action up to 30 minutes
Ondansetron Indications
- Moderate to severe nausea
- Active vomiting
- Prophylaxis for eye and spinal injuries
Ondansetron Contraindications
- Paediatrics less than 2 years old
- Hypersensitivity
Ondansetron Special Considerations
- Headache
- Malaise/fatigue
- Drowsiness
- Dizziness
- Rash/allergic reaction
Oxygen Intro
- Oxygen is a treatment for hypoxaemia and has not been shown to have any effect on breathlessness in non-hypoxaemic patients.
Oxygen Indications
Adult:
- Oxygen should be titrated to achieve oxygen saturations of between 94 – 98%, (or 88 – 92% for COPD patients). These are achieved through the use of different flow rates and oxygen masks.
Paediatric:
- All paediatric patients with significant illness or injury should receive oxygen. Newborn resuscitation should ideally be commenced with room air for the first couple of breaths.
Oxygen Contraindications
- Explosive or flammable environments
- Normoxia
Oxygen Special Considerations
- Patients with acute episodes of COPD are at risk of developing carbon dioxide retention if they are given excessive supplemental oxygen. This can cause acidosis and subsequent organ dysfunction.
- High oxygen concentrations can lead to increased production of reactive free radicals resulting in cellular damage. This may be responsible for the detrimental effects observed with the use of high flow oxygen in myocardial infarction and stroke.
Paracetamol Intro
- Paracetamol is a p-aminophenol derivative that exhibits analgesic and antipyretic activity.
- Delayed onset of action with peak effect via oral route achieved in ≥ 30 minutes.
Paracetamol Indications
Mild to moderate pain:
- For example, headache, sprain/strain, toothache, etc.
- As a component of a multimodal analgesic regime.
paracetamol Contraindications
- Known hypersensitivity to Paracetamol.
- Do not give if patient has had Paracetamol in the preceding 4 hours.
- Cannot exceed the maximum allowed single dose or exceed the maximum allowed paracetamol daily dose (24hrs).
Paracetamol Special Considerations
- Nil know at therapeutic doses
Prednisolone Intro
- Redipred Oral 30ml elixir for oral administration
- Prednisolone is a steroid. It prevents the release of inflammatory mediators
- Peak effect within 1hr
Prednisolone Indications
- Mild / Moderate croup
- Severe croup after nebulised Adrenaline administration
Prednisolone Contraindications
- Known hypersensitivity to corticosteroids
- Live virus immunisation within last 48 hours (e.g. MMR, Chicken Pox, Yellow Fever)
Prednisolone Special Considerations
- Side effects occur following prolonged use and are of little consequence in an emergency setting
- Vomiting
Salbutamol Intro
- Short acting Beta 2 agonist that causes relaxation of bronchial smooth muscle (bronchodilation).
- Onset: 2-5 minutes, maximum by 10 minutes.
Salbutamol Indications
Bronchospasm and respiratory distress associated with wheeze:
- Acute Bronchial Asthma
- Bronchitis
- Smoke inhalation
- Severe allergic / anaphylactic reactions
- Acute Pulmonary Oedema of non-cardiac origin
- Salt Water Aspiration Syndrome (SCUBA divers)
- Chronic Obstructive Pulmonary Disease (COPD)
Salbutamol Contraindications
- Known hypersensitivity to salbutamol
- Cardiogenic pulmonary oedema
- Age <12 months
Salbutamol Special Considerations
- Muscle tremor
- Tachycardia, palpitations
- Headache
Tranexamic Acid Intro
- Antifibrinolytic
- Tranexamic Acid (TXA) is a synthetic derivative of the amino acid lysine that inhibits fibrinolysis (clot breakdown) by blocking the lysine binding site on plasminogen, competitively inhibiting the activation of plasminogen to plasmin.
- Hepatic metabolism with renal excretion.
- Onset: Within minutes
Duration: 17 hours
Half-life: 3 hours
Tranexamic Acid Indications
- Significant trauma (< 3 hours) with signs of hypovolaemia or
- Significant active haemorrhage that requires the use of
- Tourniquet/s
- Haemostatic/pressure dressing/s - Suspected head injury (< 3hours) with GCS motor score of 4 (withdrawing from pain) or below
- Severe Primary or Secondary Post-Partum Haemorrhage (> 1000 mL) or PPH with signs of hypovolaemia (birth/bleed occurred < 3hrs)
- Significant post-tonsillectomy haemorrhage
Tranexamic Acid Contraindications
- Known hypersensitivity to Tranexamic Acid.
- Injury time more than 3 hours (associated with increase in mortality).
Tranexamic Acid Special Considerations
- Hypotension (fast infusion rate)
- Headache
- Dizziness
- Convulsions (lowers seizure threshold)
- Nausea and/or vomiting
- Diarrhoea
Fentanyl Special Considerations
- Adopt a low threshold to engage with the ED team if pain remains difficult to control
- Drowsiness
- Nausea/vomiting
- Respiratory depression; monitor pulse oximetry for all patients having IV / IN Fentanyl
- Cardiovascular effects:
-Bradycardia
-Hypotension (rare)
What are the Sedation Warnings for Sedative Medications
- Sedation is HIGH RISK – must only be carried out after careful deliberation between officers and must not be based primarily at the request or influence of other agencies on scene (e.g. Police etc.)
- Positive RASS score does not automatically infer a need to sedate
- Age <16 years old – sedation should prompt a prior ASMA consult wherever practicable
- ETOH / Intoxication – apply caution
- Repeat & Maintenance doses – have a low threshold to consult with ASMA where repeat or maintenance doses are required
- Monitoring – SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops (~RASS -2 or below)
- Positioning – DO NOT transport in supine position (increases risk of laryngospasm from secretions) – transport in lateral position
- Airway & Breathing – monitor airway and breathing effort, including chest movement closely for signs of impairment. Prepare to support if required
- Restraint – Prone and/or handcuffed to rear carries excessive risk and MUST NOT occur. Physical restraint in any position that amplifies the risk of positional asphyxia, must be closely observed for signs of air hunger and hypoxia
- RASS scores must be agreed and documented
- Weight – Estimated weight must be agreed before administration of any weight based medicines. This must be documented
The final decision to sedate lies with the most senior clinician on scene
Lignocaine new indications
Local anaesthesia for:
IV cannulation
IO infusion
Suturing
Finger thoracostomy in the conscious patient
Cardiac Arrest:
Cardiac Arrest with persistent or recurrent Ventricular Fibrillation/pulseless Ventricular Tachycardia, refractory to defibrillation strategies and maximum dose of Amiodarone as per Cardiac Arrest CPG
