Medicines Flashcards

Question

Amiodarone Hydrochloride AMO Side effects

Answer 1

Bradycardia. Vasodilatation causing hypotension, flushing. Bronchospasm. Arrhythmias – Torsades de pointes. EEAST Specific: When given for Tachycardia: Inflammation of the vein may occur. Rapid administration may cause flushing, sweating and nausea. Transient reduction in BP can occur. Circulatory collapse has been associated with too rapid administration. In asthmatics – bronchospasm can occur. Most other side effects occur with prolonged treatment If any untoward reactions occur these must be reported using the Yellow Card system to the MHRA. If such a report is made an internal Trust Incident Report form must be completed

Answer 2

Administer into large vein as extravasation can cause burns. Follow administration with a 0.9% sodium chloride flush – refer to Sodium Chloride 0.9%. Cardiac arrest – Shockable rhythms: if unresponsive to defibrillation administer amiodarone after the 3rd shock. Route: intravenous/intraosseous – administer as a rapid bolus. EEAST Specific: Amiodarone strength and form: 300mg pre-filled syringe 150mg amps Route/Method: Administer via central vein, or in emergency a large vein as extravasation can cause skin necrosis. Not to be given via ET route Single IV bolus — single dose (or IO < 7 years) Dosage: Cardiac arrest: Adults 300mg dose after the third shock and a further 150mg after the fifth shock is required. Tachycardia: Adults over 20 years of age: 300mg over 30 minutes (diluted into 100ml 5% dextrose). Single dose only. A PRF and QA8 audit form must be completed if this is administered.

Answer 3

EEAST Specific: Cardiac arrest - To ensure that there is no advanced directive. Tachycardia - Doubts about the ECG diagnosis of broad complex tachycardia should prompt contact via the Clinical Advice Line. If the patient is known to have existing thyroid disease. Patient requires to be under continuous ECG monitoring and to have open IV access. Care if the patient is on any drug which might increase the QT interval. Injection of Amiodarone is incompatible with saline and if diluted dextrose MUST be used . Too high a dose may lead to severe bradycardia and to conduction disturbances with the appearance of an idioventricular rhythm, particularly in elderly patients or during digitalis therapy. In these circumstances, amiodarone treatment should be withdrawn. If necessary, beta-adrenostimulants or glucagon may be given. Amiodarone induces ECG changes; QT interval lengthening corresponding to prolonged repolarisation with the possible development of U and deformed T waves; these changes are evidence of its pharmacological action and do not reflect toxicity. This product contains the preservative benzyl alcohol and should be administered with caution to infants and children up to 3 years old, as there is a risk that benzyl alcohol may cause toxic reactions and allergic reactions (anaphylactoid) in this age group.

Answer 4

Adults with: Clinical or ECG evidence suggestive of myocardial infarction or ischaemia. Suspected TIA and ALL of the following: - where symptoms are fully resolved - patient is not being conveyed to hospital - patient has been referred into local TIA pathway.

Answer 5

Has an antiplatelet action which reduces clot formation.

Answer 6

Known aspirin allergy or sensitivity. Children under 16 years (see additional information). Active gastrointestinal bleeding. Haemophilia or other known clotting disorders. Severe hepatic failure with jaundice.

Answer 7

As the likely benefits of a single 300 milligram aspirin outweigh the potential risks, aspirin may be given to patients with: Asthma Pregnancy Renal failure Moderate hepatic disease without jaundice Gastric or duodenal ulcer Current treatment with anticoagulants.

Answer 8

Increased risk of gastric bleeding. | Wheezing in some asthmatics.

Answer 9

In suspected myocardial infarction a 300 milligram aspirin tablet should be given regardless of any previous aspirin taken that day. Clopidogrel may be indicated in acute ST segment elevation myocardial infarction – refer to Clopidogrel. Aspirin is contra-indicated in children under the age of 16 years as it may precipitate Reye's syndrome. This syndrome is very rare and occurs in young children, damaging the liver and brain. It has a mortality rate of 50%.

Answer 10

``` Route: Oral – chewed or dissolved in water. AGE Adults INITIAL DOSE 300 milligrams REPEAT DOSE NONE DOSE INTERVAL N/A CONCENTRATION 300 milligrams per tablet VOLUME 1 tablet MAX DOSE 300 milligrams ```

Answer 11

Symptomatic bradycardia in the presence of ANY of these adverse signs: Absolute bradycardia (pulse <40 beats per minute). Systolic blood pressure below expected for age (refer to Page-for-Age for age related blood pressure readings in children). Paroxysmal ventricular arrhythmias requiring suppression. Inadequate perfusion causing confusion, etc. Bradycardia following return of spontaneous circulation (ROSC). NB Hypoxia is the most common cause of bradycardia in children, therefore interventions to support ABC and oxygen therapy should be the first-line therapy. Refer also to Atropine for CBRNE.

Answer 12

Should NOT be given to treat bradycardia in suspected hypothermia. Do NOT give atropine sulfate to patients with cardiac transplants; their hearts will not respond to vagal blocking by atropine and paradoxical high degree AV block or sinus arrest may result.

Answer 13

Reverses effects of vagal overdrive. Increases heart rate by blocking vagal activity in sinus bradycardia, second or third degree heart block. Enhances A-V conduction.

Answer 14

Dry mouth, visual blurring and pupil dilation. Confusion and occasional hallucinations. Tachycardia. Do not use small (<100 micrograms) doses as they may cause paradoxical bradycardia.

Answer 15

May induce tachycardia when used after myocardial infarction, which will increase myocardial oxygen demand and worsen ischaemia. Hence, bradycardia in a patient with an MI should ONLY be treated if the low heart rate is causing problems with perfusion.

Answer 16

SYMPTOMATIC BRADYCARDIA NB BRADYCARDIA in children is most commonly caused by HYPOXIA, requiring immediate ABC care, NOT drug therapy; therefore ONLY administer atropine in cases of bradycardia caused by vagal stimulation (e.g. suction). Route: Intravenous/intra-osseous administer as a rapid bolus. 600 micrograms per ml NB. The adult dosage can be given as 500 or 600 micrograms to a maximum of 3 milligrams depending on presentation available.

Answer 17

Duodote® containing 2.1 milligrams of atropine sulphate. Indications: Organophosphate (OP) poisoning. Adults and children with a clinical diagnosis of poisoning by OP nerve agents, as an adjunct to maintenance of oxygenation. Atropine should be administered for confirmed OP poisoning, or where features of OP poisoning develop. Clinical diagnosis of nerve agent poisoning (see below) is suggested by the characteristic features of nerve agent poisoning, associated with a history of possible exposure. Clinical features must include one or more of the following: bronchorrhoea, bronchospasm, severe bradycardia (<40 bpm). Contra-Indications Hypersensitivity to atropine sulphate or excipients in nerve agent poisoning. Cautions: There are no other absolute criteria for the exclusion from administration of atropine in the treatment of OP poisoning, as the consequences of not instituting prompt treatment in poisoned patients will usually outweigh the risks associated with treatment. However, caution needs to be administered in the following: Patients with ulcerative colitis. Patients with risk of urinary retention. Patients with glaucoma. Patients with conditions characterised by tachycardia (e.g. thyrotoxicosis, heart failure). Patients with myasthenia gravis. Side Effects: Reactions are mostly dose related and usually reversible and include: Loss of visual accommodation. Photophobia. Arrhythmias, transient bradycardia followed by tachycardia. Palpitations. Difficulty in micturition. Additional information: Toxic doses may cause CNS stimulation manifesting as restlessness, confusion, ataxia, lack of coordination, hallucinations and delirium. In severe intoxication CNS stimulation may give way to CNS depression, coma, circulatory and respiratory failure and death. Characteristic features of nerve agent poisoning: Miosis, excess secretions (e.g. lacrimation and bronchorrhoea). Respiratory difficulty (e.g. bronchospasm or respiratory depression). Altered consciousness, convulsions, together with a history of possible exposure. Nerve agent poisoning Atropine must only be administered after the patient is adequately oxygenated. In organophosphate poisoning there is no maximum dose and large doses (e.g. 20 milligrams) may be required to achieve atropinisation. Signs of atropinisation include: dry skin and mouth and an absence of bradycardia (e.g. heart rate adult ≥80; heart rate child HR ≥100 bpm). NB DO NOT rely on reversal of pinpoint pupils as a guide to atropinisation. Administering large volumes intramuscularly could lead to poor absorption and/or tissue damage; therefore administer the smallest volume possible and divide where necessary and practicable. Vary the site of injection for repeated doses; appropriate sites include: buttock (gluteus maximus), thigh (vastus lateralis), lateral hip (gluteus medius) and upper arm (deltoid).

Answer 18

Suspected meningococcal disease in the presence of: 1. a non-blanching rash (the classical, haemorrhagic, non-blanching rash (may be petechial or purpuric) and/or 2. signs/symptoms suggestive of meningococcal septicaemia (refer to Meningococcal Meningitis and Septicaemia for signs/symptoms).

Answer 19

Antibiotic: narrow-spectrum.

Answer 20

Known severe penicillin allergy (more than a simple rash alone).

Answer 21

Meningococcal septicaemia is commonest in children and young adults. It may be rapidly progressive and fatal. Early administration of benzylpenicillin improves outcome. Two sites should be used for IM injection when administering more than 2ml of volume.

Answer 22

Administer en-route to hospital (unless already administered). NB IV/IO and IM concentrations are different and have different volumes of administration. Route: Intravenous/intraosseous – by slow injection. Route: Intramuscular (antero-lateral aspect of thigh or upper arm – preferably in a well perfused area) if rapid intravascular access cannot be obtained. Two sites should be used for IM injection when administering more than 2ml of volume.

Answer 23

Symptomatic allergic reactions falling short of anaphylaxis but causing patient distress (e.g. severe itching). Alleviating distressing cutaneous symptoms in anaphylaxis only after emergency treatment with adrenaline and the patient is stable and oral antihistamine administration is not possible.

Answer 24

An antihistamine that blocks the effect of histamine released during a hypersensitivity (allergic) reaction.

Answer 25

Known hypersensitivity. The anticholinergic properties of chlorphenamine are intensified by monoamine oxidase inhibitors (MAOIs). Chlorphenamine injection is therefore contraindicated in patients who have been treated with MAOIs within the last 14 days.

Answer 26

``` Pregnancy and breastfeeding. Hypotension. Epilepsy. Glaucoma. Severe liver disease. ```

Answer 27

Sedation. Dry mouth. Headache. Blurred vision. Urinary retention. Psychomotor impairment. Gastrointestinal disturbance. Convulsions (rare). Children and older people are more likely to suffer side effects. Warn anyone receiving chlorphenamine against driving or undertaking any other complex psychomotor task, due to the sedative and psychomotor side effects. With the intravenous preparation, transient hypotension, central nervous system (CNS) stimulation and irritant effects.

Answer 28

Route: Intramuscular/intravenous. Small doses can be diluted with sodium chloride 0.9%. Route: Oral 4 milligram tablet. Route: Oral 2 milligrams in 5 ml solution.

Answer 29

Acute STEMI indicated for transfer to PPCI secondary to administration of aspirin.

Answer 30

Inhibits platelet aggregation

Answer 31

Known allergy to ticagrelor Active bleeding History of intercranial haemorrhage Severe hepatic impairment

Answer 32

Unlikely a concern following single dose in an emergency: ``` Asthma. Bradycardia. COPD. Hyperuricaemia. Patients at increased risk of bleeding. Second or third degree heart block. Sick sinus syndrome. Moderate hepatic impairment. pregnancy. ```

Answer 33

``` Constipation. Diarrhoea. Dyspepsia. Dyspnoea. Gout. Gouty arthritis. Bleeding. Headache. Hyperuricaemia. Hypotension. Skin reactions. Nausea. Syncope. Vertigo. ``` ``` Uncommon: Angioedema. Confusion. Intracranial haemorrhage. Tumour haemorrhage. Thrombotic thrombocytopenic purpura ```

Answer 34

180mg 2x 90mg tablets dissolved in mouth and swallowed.

Answer 35

Mild/moderate/severe croup, scored using the Modified Taussig Score, refer to Respiratory Illness in Children.

Answer 36

Corticosteroid – reduces subglottic inflammation.

Answer 37

Impending respiratory failure.

Answer 38

Upper airway compromise can be worsened by any procedure that distresses the child – this might include the administration of medication.

Answer 39

Gastro-intestinal upset. | Hypersensitivity/anaphylactic reaction.

Answer 40

A single pre-hospital dose is advised. If you feel the child needs a second dose in the same episode of illness they must be reviewed by a senior healthcare professional; seek senior clinical advice. If the child vomits less than 30 minutes after administration, the same dose can be given once again.

Answer 41

Route: Oral solution. The doses given in the following dosage chart are taken from the Summary of Product Characteristics of the oral solution licensed for use in childhood croup. The doses are calculated on average weights to give a dose of dexamethasone of 0.15mg/kg. Route: Oral tablet. Dissolve the 2 milligram tablets in water.

Answer 42

Patients who have prolonged convulsions (lasting 5 minutes or more) OR repeated convulsion (three or more in an hour), and are CURRENTLY CONVULSING – not secondary to an uncorrected hypoxic or hypoglycaemic episode (see Additional Information below). Eclamptic convulsions (initiate treatment if seizure lasts over 2–3 minutes or if it is recurrent). Symptomatic cocaine toxicity (severe hypertension, chest pain or convulsions).

Answer 43

Central nervous system depressant, acts as an anticonvulsant and sedative.

Answer 44

Should be used with caution if alcohol, antidepressants or other CNS depressants have been taken as side effects are more likely. A dose of buccal midazolam or rectal diazepam given by a parent or carer may be the first dose administered for this seizure. The first dose given by the paramedic may be the second dose of benzodiazepine given for the seizure and IV/IO access may be needed, refer to Convulsions in Adults.

Answer 45

Patients with known hypersensitivity. EEAST Specific: Known hypersensitivity to benzodiazepines or to any component of the product (see Summary of Product Characteristics). Prior administration of two doses of a benzodiazepine (any route) during the episode of care (including those given by carer from patient’s own medication). Currently presenting with Psychogenic Non-Epileptic Seizure (PNES) — follow individualised treatment plan.

Answer 46

Respiratory depression may occur, especially in the presence of alcohol (which enhances the depressive side effect of diazepam). Opioid drugs similarly enhance diazepam's cardiac and respiratory depressive effects. Hypotension may occur. This may be significant if the patient has to be moved from a horizontal position to allow for extrication from an address. Caution should therefore be exercised and consideration given to either removing the patient flat or, if the convulsion has stopped and it is considered safe, allowing a 10-minute recovery period prior to removal. Other side effects include light-headedness, unsteadiness, drowsiness, confusion and amnesia. If any untoward reactions occur these must be reported using the Yellow Card system to the MHRA. If such a report is made an internal Trust Incident Report form must be completed.

Answer 47

If the patient is prescribed buccal midazolam and a supply is available, this may be administered according to the prescriber’s instructions. Diazepam should only be used if the patient has been convulsing for 5 minutes or more, or if convulsions recur in rapid succession without time for full recovery in between (and in either case is still convulsing). There is no value in giving 'preventative' diazepam if the convulsion has ceased. In any clearly sick or ill child, there must be no delay at the scene while administering the drug – it can be administered en-route to hospital. If IV access can be gained rapidly, then this is preferable to the PR route. If buccal midazolam is available, use that in preference to gaining IV access for the first dose of diazepam. Early consideration should be given to using the buccal or PR route when IV access cannot be rapidly and safely obtained, commonly the case in children. In small children the buccal or PR route should be considered the first treatment option (with IV access being sought subsequently). When giving rectal medication, offer parental explanation and maintain patient dignity. All patients who continue to convulse should receive a total of TWO doses of benzodiazepine (midazolam or diazepam) 10 minutes apart, the second dose should be IV/IO if possible. Only give a second rectal dose if IV/IO access cannot be obtained in the 10 minutes between the first and second doses. Seek clinical advice if the convulsion continues 10 minutes after the second dose. Care must be taken when inserting rectal tubes. They should be inserted no more than 2.5 cm in children or 4–5 cm in adults. All tubes have an insertion marker on the nozzle. The full dose should be given at the appropriate times. It is not appropriate to either i) gradually 'titrate the dose upwards' or ii) to only give a partial dose if the convulsion stops (once started, even if the convulsion stops, that dose must be given). If this approach is followed, convulsion recurrence is much less likely.

Answer 48

The full dose should be given at the appropriate times for seizures. It is not appropriate to either: gradually 'titrate the dose upwards', or to only give a partial dose if the convulsion stops (once started, even if the convulsion stops, that dose must be given). Giving partial doses is likely to result in convulsion recurrence. First dose (consider any prior doses of benzodiazepine administered by parent, carer or other healthcare professional as one of the two doses in total that may be administered): Second dose 10 minutes after first dose (as above consider any prior doses of benzodiazepine administered): If patient continues to convulse 10 minutes after the second dose seek additional clinical support and advice (see ‘Arrangements for referral for medical advice’). Transport as soon as possible. Rectal Route: Rectal For convulsions give the full dose. Intravenous/intraosseous Route: Intravenous/intraosseous – administer SLOWLY over 2 minutes for adults (3–5 minutes for children). For convulsions give the full dose. In symptomatic cocaine toxicity titrate slowly to response. NB The second benzodiazepine dose should be IV/IO wherever possible (i.e. IV/IO diazepam). Where a first adult <70 years dose of 20 milligrams diazepam has been given rectally and the patient continues to fit, a second dose of 10 milligrams diazepam should be administered IV, giving a total cumulative dose of 30 milligrams diazepam. Where both first and second doses are given IV then the maximum cumulative dose is 20 milligrams. Be ready to support ventilations. Symptomatic cocaine toxicity: intravenous/intraosseous injection Adults 12 years and over: Administer by slow IV/IO injection over 2 minutes. Dose must be titrated to response in symptomatic cocaine toxicity where patients are not convulsing. Reduce the dose by half in frail and debilitated patients and in patients aged 70 years and over.

Answer 49

Consider IV furosemide for pulmonary oedema and/or respiratory distress due to acute heart failure. EEAST Specific: Secondary treatment for pulmonary oedema (nitrates are first line treatment) Inclusion criteria: Adults with Pulmonary oedema secondary to left ventricular failure (LVF)

Answer 50

Furosemide is a potent diuretic with a rapid onset (within 30 minutes) and short duration.

Answer 51

Reduced GCS with liver cirrhosis. Cardiogenic shock. Severe renal failure with anuria. Children under 18 years old.

Answer 52

Hypokalaemia (low potassium) could induce arrhythmias. Pregnancy. Hypotensive patient. Patient may already be on other diuretics — to continue regular treatment

Answer 53

Hypotension. Gastrointestinal disturbances. Use the Yellow Card System to report adverse drug reactions directly to the MHRA. Yellow Cards and guidance on its use are available at the back of the BNF.

Answer 54

Consider furosemide when the time to get the patient to hospital is prolonged.

Answer 55

Intravenous Route: Intravenous Administer SLOWLY OVER 2 minutes in accordance with the table below.

Answer 56

Hypoglycaemia, clinically suspected hypoglycaemia or unconscious patients where hypoglycaemia is considered a likely cause (blood glucose <4.0 millimoles per litre). NB Glucagon should only be administered when oral glucose administration is not possible or is ineffective, AND/OR when IV access to administer 10% glucose is not possible.

Answer 57

Glucagon is a hormone that induces the conversion of glycogen to glucose in the liver, thereby raising blood glucose levels.

Answer 58

Pheochromocytoma. | Glucagon should NOT be given by IV injection because of increased vomiting associated with IV use.

Answer 59

Low glycogen stores (e.g. recent use of glucagon or starvation). For hypoglycaemic seizures, glucose 10% IV is the preferred intervention.

Answer 60

``` Nausea, vomiting. Abdominal pain in adults. Diarrhoea in children. Hypokalaemia. Hypotension in adults. Acute hypersensitivity reaction, although this is rare. ```

Answer 61

Check whether glucagon has already been administered by a relative/carer. Glucagon should only be administered once. Confirm effectiveness by checking blood glucose 10 to 15 minutes after administration. Glucagon may take up to 15 minutes to work. Glucagon can be ineffective in the very young, older people, undernourished patients or those with hepatic disease. Glucagon is relatively ineffective once body glycogen stores have been exhausted, especially in hypoglycaemic, non-diabetic children. When treating hypoglycaemia, use all available clinical information to help decide between glucagon IM, glucose 40% oral gel, or glucose 10% IV. Hypoglycaemic patients who are convulsing should preferably be given glucose 10% IV. - If the patient is conscious, use glucose 40% gel as first line treatment. Unconscious patients will require glucose 10% IV. - A newborn baby's liver has very limited glycogen stores, so hypoglycaemia may not be effectively treated using intramuscular glucagon. Glucagon works by stimulating the liver to convert glycogen into glucose. - Glucagon may also be ineffective in some instances of alcohol-induced hypoglycaemia.

Answer 62

Intramuscular | Route: Intramuscular – antero-lateral aspect of thigh or upper arm.

Answer 63

Hypoglycaemia (blood glucose <4.0 millimoles per litre) or suspected hypoglycaemia when oral administration is not possible and a rapid improvement in clinical state and blood glucose level is required. An unconscious patient, where hypoglycaemia is considered a likely cause. Management of hypoglycaemia in patients who have not responded to the administration of IM Glucagon after 10 minutes. EEAST Specific: Hypoglycaemia that could not be corrected with IM or SC glucagon injection.

Answer 64

Reversal of hypoglycaemia by direct delivery of glucose (sugar) to the systemic circulation.

Answer 65

Flush IV line thoroughly with sodium chloride 0.9% after administration to reduce vein irritation from residual glucose injection, refer to Sodium Chloride 0.9%.

Answer 66

IM or subcutaneous injection.

Answer 67

When treating hypoglycaemia, use all available clinical information to help decide between Glucose 10% IV, Glucose 40% oral gel, or Glucagon IM. The IO route of administration may be used in exceptional cases when IV access cannot be obtained and other methods are not possible/effective. There is an increased risk of osteomyelitis compared to isotonic fluids.

Answer 68

IV infusion: Peripherally via secure cannula into large vein or central access as Glucose 10% is an irritant, especially if extravasation occurs. If the patient has shown no response, the dose may be repeated after 5 minutes. If the patient has shown a PARTIAL response then a further infusion may be necessary, titrated to response to restore a normal GCS. If after the second dose there has been NO response, pre-alert and transport rapidly to further care. Consider an alternative diagnosis or the likelihood of a third dose en-route benefiting the patient. Intravenous/intraosseous infusion Route: Intravenous/intraosseous infusion. EEAST Specific: Adults It is appropriate to cannulate with the largest bore cannula — its position in the vein should be confirmed by a 10–20 ml flush of sodium chloride 0.9%. The glucose solution should be administered by IV infusion approximately 100ml (10g glucose) at a time. The dose may be repeated after 5 minutes if there is no response. If the patient has shown a partial response then further infusion may be necessary, titrated to response, up to a maximum of 300ml (30g) to restore a normal Glasgow Coma Score (GCS). If after the second dose there has been no response, consideration should be given to alternative diagnoses or the likelihood of a third dose en route to hospital.

Answer 69

Risk of extravasation Refer to SPC or current BNF for full details. Use the Yellow Card System to report adverse drug reactions directly to the MHRA. Yellow Cards and guidance on its use are available at the back of the BNF.

Answer 70

Known or suspected hypoglycaemia in a conscious patient where there is no risk of choking or aspiration.

Answer 71

Rapid increase in blood glucose levels via buccal absorption.

Answer 72

Altered consciousness – risk of choking or aspiration (in such circumstances glucose gel can be administered by soaking a gauze swab and placing it between the patient's lip and gum to aid absorption).

Answer 73

Can be repeated as necessary in the hypoglycaemic patient. Treatment failure should prompt the use of an alternative such as glucagon IM or glucose 10% IV. Refer to Glucagon or Glucose 10%.

Answer 74

The gel should be squeezed into the mouth between the teeth and gums. Route: Buccal – Measure blood glucose level after each dose. NB Assess more frequently in children who require a smaller dose for a response. This medicine should only be administered if the child has a gag reflex. NB Consider IM glucagon or IV glucose 10% if no clinical improvement.

Answer 75

Cardiac chest pain due to angina or myocardial infarction, when systolic blood pressure is greater than 90mmHg. Breathlessness due to pulmonary oedema in acute heart failure when systolic blood pressure is greater than 110mmHg. Patients with suspected cocaine toxicity presenting with chest pain.

Answer 76

A potent vasodilator drug resulting in: Dilatation of coronary arteries/relief of coronary spasm. Dilatation of systemic veins resulting in lower pre-load. Reduced blood pressure.

Answer 77

Patients with suspected posterior myocardial infarction or right-ventricular infarction. NB To reduce the risk of cross-contamination between patients, the nozzle of the spray must not come into contact with the patient’s mouth. Wipe after each use with a detergent wipe.

Answer 78

Hypotension (systolic blood pressure < 90mmHg in angina/myocardial infarction, or < 110 mmHg in acute heart failure). Hypovolaemia. Head trauma. Cerebral haemorrhage. Sildenafil (Viagra) and other related drugs – glyceryl trinitrate must not be given to patients who have taken sildenafil or related drugs within the previous 24 hours. Profound hypotension may occur. Unconscious patients. Known severe aortic or mitral stenosis.

Answer 79

Headache. Dizziness. Hypotension.

Answer 80

GTN tablets must be discarded 8 weeks after first opening.

Answer 81

The oral mucosa must be moist for GTN absorption, moisten if necessary. ANGINA or MYOCARDIAL INFARCTION (systolic BP >90 mmHg) Route: Sublingual tablet/spray (administer under the patient’s tongue and close mouth). NB The effect of the first dose should be assessed over 5 minutes; further doses can be administered provided the systolic blood pressure is >90 mmHg. Remove the tablet if side effects occur, for example, hypotension. ACUTE HEART FAILURE (systolic BP >110 mmHg) Route: Sublingual tablet/spray (administer under the patient’s tongue and close mouth). NB The effect of the first dose should be assessed over 5 minutes; further doses can be administered provided the systolic blood pressure is >110 mmHg. Remove the tablet if side effects occur, for example, hypotension.

Answer 82

ST-elevation myocardial infarction (STEMI) where heparin is required as adjunctive therapy with tenecteplase to reduce the risk of re-infarction. It is extremely important that the initial bolus dose is given at the earliest opportunity prior to administration of thrombolytic agents and a heparin infusion is commenced immediately on arrival at hospital. A further intravenous bolus dose of 1,000 units heparin may be required if a heparin infusion HAS NOT commenced within 45 minutes of the original bolus of thrombolytic agent.

Answer 83

Anticoagulant.

Answer 84

``` Haemophilia and other haemorrhagic disorders. Thrombocytopenia. Recent cerebral haemorrhage. Severe hypertension. Severe liver disease. Oesophageal varices. Peptic ulcer. Major trauma. Recent surgery to eye or nervous system. Acute bacterial endocarditis. Spinal or epidural anaesthesia. ```

Answer 85

Haemorrhage – major or minor.

Answer 86

Analysis of MINAP data suggests inadequate anticoagulation following pre-hospital thrombolytic treatment is associated with increased risks of re-infarction. AT HOSPITAL it is essential that the care of the patient is handed over as soon as possible to a member of hospital staff qualified to administer the second bolus (if not already given) and commence a heparin infusion.

Answer 87

Heparin dosage when administered with TENECTEPLASE. | Route: Intravenous single bolus unfractionated heparin.

Answer 88

Severe or life-threatening asthma. Acute exacerbation of COPD. Adrenal crisis (including Addisonian crisis) which is a time-critical medical emergency with an associated mortality. Adrenal crisis may occur in patients on long-term steroid therapy, either: - as replacement therapy for adrenal insufficiency from any cause, - in long-term therapy at doses of 5+ mg prednisolone, e.g. for immune suppression. Administer hydrocortisone to: Patients in an established adrenal crisis (IV or IM administration preferable). Ensure parenteral hydrocortisone is given prior to transportation. Patients with suspected adrenal insufficiency or on long-term steroid therapy who have become unwell, to prevent them having an adrenal crisis (IM administration is usually sufficient). Pregnant women with known Addison’s Disease who are in established labour (regular painful contractions). NB If in doubt about adrenal insufficiency, it is better to administer hydrocortisone.

Answer 89

Glucocorticoid drug that restores blood pressure, blood sugar, cardiac synchronicity and volume. High levels are important to survive shock. Therapeutic actions include suppression of inflammation and immune response.

Answer 90

Known allergy to the product/excipients. | Where a patient has adrenal crisis it is preferable to give whatever preparation is available.

Answer 91

None relevant to a single dose. | Avoid intramuscular administration if patient likely to require thrombolysis.

Answer 92

Both sodium phosphate and sodium succinate solutions contain significant amounts of phosphate preservative and may cause stinging or burning sensations.

Answer 93

Severe or life-threatening asthma, acute exacerbation of COPD, adrenal crisis, pregnant women with Addison’s disease in established labour. NB If there is any doubt about previous steroid administration, it is better to administer further hydrocortisone. There is no toxic dose for hydrocortisone, but advanced hypocortisolaemia may rapidly prove fatal. Route: Intravenous (SLOW injection over a minimum of 2 minutes to avoid side effects) OR Intramuscular (upper arm or thigh). NB Patients with a higher BMI will need a longer IM needle.

Answer 94

Relief of mild to moderate pain. Pyrexia with discomfort (may help to relieve the misery and often unpleasant symptoms that often accompany febrile illness, e.g. aches and pains). Soft tissue injuries. Best when used as part of a balanced analgesic regimen.

Answer 95

Analgesic (relieves pain). Antipyretic (reduces temperature). Anti-inflammatory (reduces inflammation).

Answer 96

Do NOT administer if the patient is: Dehydrated. Hypovolaemic. Known to have renal insufficiency. Patients with active upper gastrointestinal disturbance (e.g. oesophagitis, peptic ulcer, dyspepsia). A woman in the last trimester of pregnancy. A child with chickenpox. A patient who has previously shown hypersensitivity reactions (e.g. asthma, rhinitis, angioedema or urticaria), in response to ibuprofen, aspirin or other non-steroidal anti-inflammatory drugs. A patient with active peptic ulcer/haemorrhage. Patient with severe heart failure (NYHA Class IV), renal failure or hepatic failure. Patients on anticoagulant drugs, e.g. warfarin, direct oral anticoagulants (DOACs). Avoid giving further non-steroidal anti-inflammatory drugs (NSAIDs) (i.e. ibuprofen), if an NSAID containing product (e.g. diclofenac, naproxen) has been used within the previous 4 hours or if the maximum cumulative daily dose has already been given. Do NOT offer non-steroidal anti-inflammatory drugs (NSAIDs) to frail or older adults with fractures.

Answer 97

Asthma: Use cautiously in asthmatic patients due to the possible risk of hypersensitivity and bronchoconstriction. If an asthmatic has not used NSAIDs previously, do not use acutely in the pre-hospital setting. Older people: Exercise caution in older patients (>65 years old) that have not used and tolerated NSAIDs recently. Patients with coagulation defects. Crohn’s disease and ulcerative colitis as condition may be exacerbated. Avoid in patients with established ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, congestive heart failure. Hypertension.

Answer 98

May cause nausea, vomiting and tinnitus.

Answer 99

Route: Oral.

Answer 100

Acute, severe or life-threatening asthma. Acute asthma unresponsive to salbutamol. Exacerbation of chronic obstructive pulmonary disease (COPD), unresponsive to salbutamol.

Answer 101

Ipratropium bromide is an antimuscarinic bronchodilator drug. It may provide short-term relief in acute asthma, but beta2 agonists (such as salbutamol) generally work more quickly. Ipratropium is considered of greater benefit in: a.children suffering acute asthma b.adults suffering with COPD.

Answer 102

None in the emergency situation.

Answer 103

Ipratropium should be used with care in patients with: Glaucoma (protect the eyes from mist). Pregnancy and breastfeeding. Prostatic hyperplasia. If COPD is a possibility limit nebulisation with oxygen to 6 minutes.

Answer 104

``` Nausea. Dry mouth (common). Tachycardia/arrhythmia. Paroxysmal tightness of the chest. Allergic reaction. ```

Answer 105

``` AGE Adult INITIAL DOSE 500 micrograms REPEAT DOSE NONE DOSE INTERVAL N/A CONCENTRATION 250 micrograms in 1 ml VOLUME 2 ml MAX DOSE 500 micrograms ``` In life-threatening or acute severe asthma: undertake a TIME CRITICAL transfer to the NEAREST SUITABLE RECEIVING HOSPITAL and provide nebulisation en-route. If COPD is a possibility limit nebulisation to 6 minutes. Route: Nebuliser with 6–8 litres per minute oxygen (refer to Oxygen).

Answer 106

The treatment of nausea or vomiting in adults aged 18 and over. Prevention and treatment of nausea and vomiting following administration of morphine sulfate.

Answer 107

An anti-emetic which acts centrally as well as on the gastrointestinal tract.

Answer 108

``` Age less than 18 years. Renal failure. Phaeochromocytoma. Gastrointestinal obstruction. Perforation/haemorrhage/3–4 days after GI surgery. Cases of drug overdose. ```

Answer 109

If patient is likely to require thrombolysis then intramuscular administration of any drug should be avoided.

Answer 110

Severe extra-pyramidal effects are more common in children and young adults. Drowsiness and restlessness. Cardiac conduction abnormalities following IV administration. Diarrhoea. Rash.

Answer 111

Metoclopramide should always be given in a separate syringe to morphine sulphate. The drugs must not be mixed.

Answer 112

``` AGE ≥18 years INITIAL DOSE 10 milligrams REPEAT DOSE NONE DOSE INTERVAL N/A CONCENTRATION 10 milligrams in 2 ml VOLUME 2 ml MAX DOSE 10 milligrams ``` Route: administer by intramuscular injection or slow intravenous injection over at least 3 minutes. NB Monitor pulse, blood pressure, respiratory rate and cardiac rhythm before, during and after administration.

Answer 113

Patients who have prolonged convulsions (lasting 5 minutes or more), OR repeated convulsions (three or more in an hour), and are CURRENTLY CONVULSING – not secondary to an uncorrected hypoxic or hypoglycaemic episode. Convulsion continuing 10 minutes after first dose of medication. A PGD is required to administer midazolam unless a patient has their own prescribed supply. If the midazolam is prescribed for the patient the clinician MUST follow the prescriber’s instructions for its administration. If a PGD is being used the document will state the clinical situation in which the medicine can be administered. EEAST Specific: Fitting Adult: 1–2mg IV to effect. Paediatric: Buccal (single dose) — 1–6 months 300mcg/kg-max 2.5mg, 6m–1yr 2.5mg, 1–5yrs 5mg, 5–10 yrs 7.5mg, 10–18yrs 10mg. - For buccal administration, injection solution may be given (off-license). Paediatric: IV (off license) — 1 month–18yrs 150-200mcg/kg (0.15-0.2mg/kg) to a maximum of 2mg under this PGD.

Answer 114

Short-acting benzodiazepine with anxiolytic, sedative and anticonvulsant properties. Onset of action is dependent on the route of administration. The buccal route onset of action is usually within 5 minutes. The sedative effect decreases from 15 minutes onwards.

Answer 115

Always check the dose of the midazolam presentation carefully. Administration can lead to respiratory depression leading to respiratory arrest. Susceptible patients are children, adults over 60 years and those with chronic illness (renal, hepatic or cardiac). Enhanced side effects when alcohol or other sedative drugs are present.

Answer 116

Respiratory depression. Hypotension. Reduced level of consciousness leading to impaired airway control. Confusion leading to increased agitation. Amnesia in some patients. EEAST Specific: Bradycardia, chest pain and decreases in cardiac output, stroke volume and systemic vascular resistance. Central nervous system depression Hypotension Respiratory depression Coma Drowsiness Dizziness Muscle weakness Ataxia With the following reported less frequently: Confusion, depression, fatigue, headache, reduced alertness, numbed emotions, appetite change, sleep disturbance, dermatological reactions, visual disturbance, blood dyscrasias, transient retrograde amnesia If any untoward reactions occur these must be reported using the Yellow Card system to the MHRA http://yellowcard.mhra.gov.uk/ If such a report is made an internal Trust form must be completed.

Answer 117

When administered for convulsions in known epileptic patients ask/look to see if the patient has an individualised treatment plan or an Epilepsy Passport. Aim to follow patient's own treatment plan when possible and effective. Carefully monitor vital signs for delayed respiratory or cardiovascular side effects as the effect of the midazolam and other drugs such as rectal diazepam reach a peak effect.

Answer 118

Convulsions Route: Buccal. ``` AGE Adult INITIAL DOSE 10 milligrams REPEAT DOSE 10 milligrams DOSE INTERVAL 10 mins CONCENTRATION 5 milligrams in 1 ml VOLUME 2 ml pre-filled syringe MAX DOSE 20 milligrams ``` EEAST Specific: Route/Method: Slow intravenous injection - The IV injection of midazolam should be given slowly at a rate of approximately 1 mg in 30 seconds. Dosage Midazolam is a potent sedative agent that requires titration and slow administration. Titration is strongly recommended to safely obtain the desired level of sedation according to the clinical need, physical status, age and concomitant medication. In adults over 60 years, debilitated or chronically ill patients and paediatric patients, dose should be determined with caution and risk factors related to each patient should be taken into account. Standard dosages are provided in the table below.

Answer 119

Post-partum haemorrhage (PPH) within 24 hours of birth where bleeding from the uterus is uncontrollable by uterine massage and use of Syntometrine. Life-threatening obstetric bleeding less than 24 weeks pregnant where a miscarriage has been confirmed (e.g. confirmed by ultrasound scan, or when a miscarriage is being managed at home with medical treatment or a fetus has definitely been passed and seen). Life-threatening bleeding is normally more than 500mls OR when signs of shock are present. NB Misoprostol should only be used if other oxytocics are unavailable or if they have been ineffective at reducing haemorrhage after 15 minutes. NB Misoprostol should be used as first-line drug treatment for PPH in pre-eclampsia or hypertension where BP is 140/90 mmHg or more (or where systolic BP alone is 150 mmHg or more). Syntometrine (ergometrine and oxytocin) is contra-indicated in hypertension.

Answer 120

Stimulates contraction of the uterus. | Onset of action 7–10 minutes.

Answer 121

Any bleeding in pregnancy if there is any suspicion that the fetus or embryo is in the uterus (‘in utero’). In labour, prior to the birth of the baby (with a multiple pregnancy, ensure all babies have delivered). Known hypersensitivity to misoprostol. Secondary post-partum haemorrhage (excess bleeding more than 24 hours after delivery of the baby).

Answer 122

``` Abdominal pain. Nausea and vomiting. Diarrhoea. Pyrexia. Shivering. ```

Answer 123

Oxytocin and misoprostol reduce bleeding from a pregnant uterus through different pathways; therefore if one drug has not been effective after 15 minutes, the other may be administered in addition.

Answer 124

Tablet containing misoprostol: 200 micrograms. Administer sublingually unless the patient is unable to maintain their airway. The vaginal route is not appropriate in post-partum haemorrhage or for miscarriage, but the rectal route may be considered when appropriate (e.g. impaired consciousness). Route: Sublingual. ``` AGE Adult INITIAL DOSE 800 micrograms REPEAT DOSE None DOSE INTERVAL N/A CONCENTRATION 200 micrograms per tablet VOLUME 4 tablets MAX DOSE 800 micrograms ``` Route: Rectal. ``` AGE Adult INITIAL DOSE 800 micrograms REPEAT DOSE None DOSE INTERVAL N/A CONCENTRATION 200 micrograms per tablet VOLUME 4 tablets MAX DOSE 800 micrograms ``` NB At the time of publication there is no rectal preparation of misoprostol – therefore the same tablets can be administered sublingually or rectally.

Answer 125

Pain associated with suspected myocardial infarction (analgesic of first choice). Severe pain as a component of a balanced analgesia regimen. The decision about which analgesia and which route should be guided by clinical judgement. Refer to Pain Management in Adults and Pain Management in Children. Indications specific to Adults at the End of Life: Using ambulance service issue morphine for end of life should only be followed in situations where: A patient's own medication for pain or breathlessness has not been prescribed. The patient's own medication is not yet available or has run out. Medicines are in place without a patient-specific document signed by an independent prescriber. Wherever possible, liaison should occur with palliative care/nursing teams in line with local pathways, particularly if ‘anticipatory’ or ‘just in case’ medicines are prescribed and are available. Consider discussing with a senior clinician for advice and support, preferably a clinician with expertise in end of life care before administering morphine. Follow local pathways to access senior clinician support. If a patient has their own prescribed morphine, use this. For both breathlessness and pain management in adults, refer to the End of Life Care guideline. Breathlessness: Patient is at end of life, and is distressed and breathless. Reversible causes of breathlessness should always be considered first. If you are unable to access rapid community/palliative care, morphine should be administered. Administration must be in conjunction with pain score monitoring. The route of administration must be clinically justified and the rationale for the decision must be recorded in the PRF. Pain: Patient is at end of life and is in pain.

Answer 126

Morphine is a strong opioid analgesic. Morphine produces sedation, euphoria and analgesia; it may both depress respiration and induce hypotension. Histamine is released following morphine administration and this may contribute to its vasodilatory effects. This may also account for the urticaria and bronchoconstriction that are sometimes seen. Actions specific to Adults at the End of Life: Morphine is particularly useful for treating continuous, severe musculoskeletal and soft tissue pain, and for distress associated with breathlessness at end of life.

Answer 127

Do NOT administer morphine in the following circumstances: Children under 1 year of age. Respiratory depression (adult <10 breaths per minute, child <20 breaths per minute). Hypotension (actual, not estimated, systolic blood pressure <90 mmHg in adults, <80 mmHg in school children, <70 mmHg in pre-school children). Head injury with significantly impaired level of consciousness (e.g. below P on the AVPU scale or below 9 on the GCS). Known hypersensitivity to morphine. Contra-indications specific to Adults at the End of Life: Once the clinician has confirmed the patient has pain and/or breathlessness, and is at the end of life, then the benefits of morphine clearly outweigh treatment-related adverse effects. Cautions and contra-indications do not generally apply; the focus should be on symptom control for the patient to ensure a peaceful and dignified death. It is important that palliative care specialists involved in the patient’s care should be consulted as part of the assessment process. The use of the subcutaneous route also reduces the likelihood of some of these adverse effects.

Answer 128

Known severe renal or hepatic impairment – smaller doses may be used carefully and titrated to effect. Use with extreme caution (minimal doses) during pregnancy. NB Not to be used for labour pain where Nitrous Oxide (Entonox®) is the analgesic of choice. Use morphine WITH GREAT CAUTION in patients with chest injuries, particularly those with any respiratory difficulty, although if respiration is inhibited by pain, analgesia may actually improve respiratory status. Any patients with other respiratory problems (e.g. asthma, COPD). Head injury. Agitation following head injury may be due to acute brain injury, hypoxia or pain. The decision to administer analgesia to an agitated head injured patient is a clinical one. It is vital that if such a patient receives opioids they are closely monitored since opioids can cause disproportionate respiratory depression, which may ultimately lead to an elevated intracranial pressure through a raised arterial pCO2. Acute alcohol intoxication. All opioid drugs potentiate the central nervous system depressant effects of alcohol and they should therefore be used with great caution in patients who have consumed significant quantities of alcohol. Medications. Prescribed antidepressants, sedatives or major tranquillisers may potentiate the respiratory and cardiovascular depressant effects of morphine. Morphine may not be the appropriate treatment for a headache when the cause for the headache is uncertain, for example, a possible migraine. Smaller doses should be considered for patients weighing less than 50kg, and for frail and/or older patients who may be more susceptible to complications. Cautions specific to Adults at the End of Life: For pain in the last days or hours of life when the patient is in the dying phase, morphine may be given with caution for patients with a systolic blood pressure of 90mmHg or less. If the patient has been prescribed their own ‘anticipatory’ or ‘just in case’ medications for pain, and this medicine is available, then administer the medication from the patient’s own supply, in liaison with the palliative care or nursing team. Check for prior opioid use before administration to avoid overdosing the patient. EEAST Specific: Check that the patient has not taken any non-prescribed doses of opioid medicine. Many over-the-counter analgesics contain codeine but codeine is also found in some dry cough medicines. Remain alert to the possibility that the patient may also have taken opioid medication prescribed for another person. Codeine can be prescribed for diarrhoea so ask specifically about opioid use not just analgesic use. Morphine frequently induces nausea and the movement of the ambulance may exaggerate this. In palliative care opioid toxicity may present as subtle agitation, seeing shadows at the periphery of the visual field, vivid dreams, visual and auditory hallucinations, confusion, and myoclonic jerks. Agitated confusion may be interpreted as uncontrolled pain and further opioids given. A vicious cycle then follows, in which the patient is given sedation and may become dehydrated, resulting in the accumulation of opioid metabolites and further toxicity. May antagonise GI effects of domperidone and metoclopramide. Increased sedation with alcohol, tricyclic anti-depressants, hypnotics, antipsychotics and anxiolytics. Metabolism of morphine inhibited by cimetidine so potential risk of side-effects.

Answer 129

``` Respiratory depression. Cardiovascular depression. Nausea and vomiting. Drowsiness. Pupillary constriction. ```

Answer 130

Morphine injection is a Class A controlled drug under Schedule 2 of the Misuse of Drugs Regulations 2001. It is subject to the Safe Custody Regulations 1973, and must be stored securely with its movements recorded in a controlled drug register. Its administration and supply is strictly controlled, and it may only be possessed and administered by healthcare professionals authorised in the legislation. Unused morphine in open vials or syringes must be discarded in the presence of a witness. Morphine is not licensed for use in children but its use has been approved by the Medicines and Healthcare Products Regulatory Agency (MHRA) for ‘off label’ use. This means that it can legally be administered under these guidelines by paramedics. Additional Information specific to Adults at the End of Life: Consider, identify and treat any reversible causes of pain and/or breathlessness.

Answer 131

Naloxone can be used to reverse morphine related respiratory or cardiovascular depression. It should be carefully titrated after assessment and appropriate management of ABC for that particular patient and situation, refer to Naloxone Hydrochloride. Morphine frequently induces nausea or vomiting which may be potentiated by the movement of the ambulance. Titrating to the lowest dose to achieve analgesia will reduce the risk of vomiting. The use of an anti-emetic should also be considered whenever administering any opioid analgesic, refer to Ondansetron and Metoclopramide Hydrochloride. Special Precautions specific to Adults at the End of Life: The use of Naloxone in palliative care is not routinely practised and is only indicated in circumstances where a clinician suspects opioid induced toxicity, from intentional or unintentional overdose. The aim is to reverse life-threatening respiratory depression only i.e. if the respiratory rate is <8 breaths per minute and the patient is unconscious and or cyanosed. Refer to the End of Life Care guideline opioid administration in the last hours of life and for death after drug administration.

Answer 132

Administration must be in conjunction with pain score monitoring, refer to Pain Management in Adults and Pain Management in Children. Intravenous morphine takes a minimum of 2–3 minutes before starting to take effect, reaching its peak between 10–20 minutes. The absorption of intramuscular, subcutaneous or oral morphine is variable, particularly in patients with major trauma, shock and cardiac conditions; these routes should preferably be avoided if the circumstances favour intravenous or intraosseous administration. Morphine should be diluted with sodium chloride 0.9% to make a concentration of 10 milligrams in 10 ml (1 milligram in 1 ml) unless it is being administered by the intramuscular or subcutaneous route when it should not be diluted. ADULTS – If pain is not reduced to a tolerable level after 10 milligrams of IV/IO morphine, then further 2 milligrams doses may be administered by slow IV/IO injection every 5 minutes to 20 milligrams maximum. The patient should be closely observed throughout the remaining treatment and transfer. Smaller doses should be considered for lightweight children over age 12 and for older, frail patients who may be more susceptible to complications. CHILDREN – The doses and volumes given below are for the initial and maximum doses. Administer 0.1 ml/kg (equal to 100 micrograms/kg) as an initial slow IV injection over 2 minutes. If pain is not reduced to a tolerable level after 5 minutes then a further dose of up to 100 micrograms/kg, titrated to response, may be repeated (maximum dose 200 micrograms/kg). NOTE: Peak effect of each dose may not occur until 10–20 minutes after administration. Intravenous/intraosseous (NOT end of life) Route: Intravenous/intraosseous – administer by slow IV injection (rate of approximately 2 milligrams per minute, titrate to effect up to initial dose). Observe the patient for at least 5 minutes after completion of initial dose before repeating the dose if required. Smaller initial doses (e.g. 1 milligram) should be used for frail and/or older patients. ``` AGE Adult ≥ 50kg Adult < 50kg INITIAL DOSE 10 milligrams 2 milligrams REPEAT DOSE 10 milligrams 2 milligrams DOSE INTERVAL 5 minutes 4 minutes CONCENTRATION 10 milligrams in 10 ml 10 milligrams in 10 ml VOLUME 10 ml 2 ml MAX DOSE 20 milligrams 10 milligrams ``` Subcutaneous/intramuscular (NOT end of life) Route: Subcutaneous/intramuscular. NB For patients with major trauma, shock, or cardiac conditions, administer via IV/IO routes. Only administer via the subcutaneous or intramuscular route if the IV/IO routes are not accessible. For administration by the subcutaneous or intramuscular route, do not dilute the morphine, as more than 1 ml of fluid injected into the site of administration is not recommended. The effects of SC/IM morphine are evident after 15–20 minutes. Smaller initial doses (e.g. 1 milligram) should be used for frail and/or older patients. AGE Adult ≥ 50kg Adult < 50kg INITIAL DOSE 10 milligrams 5 milligrams REPEAT DOSE 10 milligrams 5 milligrams DOSE INTERVAL 60 minutes 60 minutes CONCENTRATION 10 milligrams in 1 ml 10 milligrams in 1 ml VOLUME 1 ml 0.5 ml MAX DOSE 20 milligrams 10 milligrams ``` Oral (NOT end of life) Route: Oral. NB Only administer via the oral route in patients with major trauma, shock or cardiac conditions if the IV/IO routes are not accessible. AGE Adult ≥ 12 years INITIAL DOSE 20 milligrams REPEAT DOSE 20 milligrams DOSE INTERVAL 60 minutes CONCENTRATION 10 milligrams in 5 ml VOLUME 10 ml MAX DOSE 40 milligrams ```

Answer 133

Pain End of Life – Subcutaneous/intramuscular Route: Subcutaneous/intramuscular. The subcutaneous route is the preferred route for pain management at the end of life. However, the intramuscular route can also be used. For administration by the subcutaneous or intramuscular route, do not dilute the morphine, as more than 1 ml of fluid injected into the site of administration is not recommended. The effects of SC/IM morphine are evident after 15–20 minutes. Breathlessness End of Life – Subcutaneous/intramuscular Route: Subcutaneous/intramuscular. Reversible causes of breathlessness should always be considered first. Consider discussing with a senior clinician for advice and support, preferably a clinician with expertise in end of life care before administering morphine for breathlessness. Follow local pathways to access senior clinician support. Patient at end of life, in distress, and breathless. Patient has no anticipatory medicines in place. You are unable to access rapid community/palliative care. If the patient remains breathless, consider prompt referral to community/palliative care to consider administration of appropriate medications such as subcutaneous morphine administration via a syringe driver. Follow local procedures for access to local pathways and how to access senior clinician support. Other medications may need to be administered for breathlessness and anxiety such as lorazepam, midazolam, antiemetic-haloperidol and a stimulant laxative (senna).

Answer 134

The reversal of acute opioid or opiate toxicity for respiratory arrest or respiratory depression. Unconsciousness, associated with respiratory depression of unknown cause, where opioid overdose is a possibility. Refer to Altered Level of Consciousness. In cardiac arrest, where opioid toxicity is considered to be the likely cause. Patients exposed to high-potency veterinary or anaesthetic preparations should be given naloxone urgently if: Consciousness is impaired OR Exposure occurred within the last 10 minutes, even if asymptomatic. If an antidote is supplied with the opioid medication, such as diprenorphine (Revivon) or naloxone, it should be administered immediately.

Answer 135

Complete or partial reversal of the respiratory depression effects of opioid drugs. The aim of naloxone administration is to restore adequate respirations but not necessarily to restore full consciousness.

Answer 136

Neonates born to opioid addicted mothers can suffer from serious withdrawal effects. Emphasis should be on bag-valve-mask ventilation and oxygenation.

Answer 137

In patients who are physically dependent on opioids, naloxone may precipitate violent withdrawal symptoms, including cardiac arrhythmias. It is better, in these cases, to titrate the dose of naloxone as described in the dosing charts in this guideline to effectively reverse the cardiac and respiratory depression, but still leave the patient in a ‘groggy’ state with regular reassessment of ventilation and circulation. Vomiting is a common side effect following naloxone administration, ensure access to suction.

Answer 138

When indicated, naloxone can be administered via the intravenous, intramuscular, intraosseous, subcutaneous or intranasal route. Very ill patients will require intravenous naloxone to ensure rapid absorption of the total dose. Refer to local procedures/product instructions for the route of administration and for intranasal dose and time intervals. For intramuscular administration, the drug should be undiluted (into the outer aspect of the thigh or upper arm). Absorption may be unpredictable. All cases of opioid overdose should be transported to hospital, even if the initial response to naloxone has been good. The duration of action of naloxone is usually 30 to 90 minutes and this is shorter than some opioids such as methadone; therefore additional doses of naloxone may be necessary to maintain reversal of opioid induced respiratory depression. Patients who have ingested methadone require observation for at least 8 hours following overdose to prevent accidental death. If the patient refuses to go to hospital, consider, if the patient consents, a loading dose of 800 micrograms IM to minimise the risk described above. For patients who refuse transfer to hospital if possible leave in the care of a responsible adult and leave an advice leaflet advising of action to be taken in the event that the symptoms return. Some patients at risk of opiate misuse (or their carers) may have been given take home naloxone as a harm-reduction measure. The large difference in doses between adult and children reflects the likely aetiology of the opiate ingestion and aims of treatment. In children aged under 12, the aetiology is likely to be accidental ingestion and they are unlikely to be dependent on opiates (unless they are an end of life care patient) so the aim is to totally reverse the opiate. If you feel the child needs further doses in the same episode of illness they must be reviewed by a senior healthcare professional; seek senior clinical advice. Adults are more likely to be dependant opiate users and may become aggressive if the opiate is reversed, so the aim is a controlled reversal. Methadone is a long-acting synthetic opioid that is used in opioid harm reduction and substance misuse programmes. Methadone has an elimination half-life of between 15 and 60 hours, in contrast to the shorter-acting naloxone which has a half-life of 1 to 1.5 hours. Cautions for End of Life Care Patients: The use of naloxone in palliative care is not routinely practised, as patients on regular opioids can be physically dependant. It is only indicated in circumstances where a clinician suspects opioid-induced toxicity, from intentional or unintentional overdose. The aim is to reverse life-threatening respiratory depression only i.e. if the respiratory rate is <8 breaths per minute and the patient is unconscious and or cyanosed. Refer to End of Life Care.

Answer 139

Respiratory arrest/respiratory depression Route: Intravenous/intraosseous For adults who may be opiate dependant: administer slowly, 1 ml at a time. Titrate to response relieving respiratory depression but maintain patient in ‘groggy’ state. For known or potentially aggressive adults suffering respiratory depression: dilute up to 800 micrograms (2 ml) of naloxone into 8 ml of water for injections or sodium chloride 0.9% to a total volume of 10 ml and administer slowly, titrating to response, 1 ml at a time. If there is no response after the initial dose, repeat the dose, up to the maximum dose or until an effect is noted. NB The duration of action of naloxone is short. ``` PLEASE NOTE: For children using the IV/IO route, the initial dose is much higher than that for adults with the aim of totally reversing the opiate effect as quickly as possible. Please read dosages carefully. Seek advice to exceed the maximum dose as per local procedures. AGE ≥12 years INITIAL DOSE 400 micrograms REPEAT DOSE 400 micrograms DOSE INTERVAL 3 minutes CONCENTRATION 400 micrograms in 1 ml VOLUME 1 ml MAX DOSE 4,000 micrograms ``` Respiratory arrest/respiratory depression where the IV/IO route is unavailable or the ambulance clinician is not trained to administer drugs via the IV/IO route: Route: Intramuscular/subcutaneous. Only use this route if the IV/IO route is not available. If there is no response after the initial dose, give up to the maximum dose or until an effect is noted. NB the half-life of naloxone is short. For children: give the full dose with the aim of totally reversing the opiate effects. ``` Administering large volumes via the intramuscular route could lead to poor absorption and/or tissue damage. Therefore, divide the dose where necessary and practicable. Vary the site of injection for repeated doses. AGE ≥12 years INITIAL DOSE 400 micrograms REPEAT DOSE 400 micrograms DOSE INTERVAL 3 minutes CONCENTRATION 400 micrograms in 1 ml VOLUME 1 ml MAX DOSE 4,000 micrograms ``` Respiratory arrest/respiratory depression Route: Intranasal BOTH nostrils should be used, with 0.5 ml (a half dose) to each nostril. AGE INITIAL DOSE 0.5 ml (200 micrograms) to each nostril (1 ml total) REPEAT DOSE 0.5 ml (200 micrograms) to each nostril (1 ml total) DOSE INTERVAL 3 minutes CONCENTRATION 400 micrograms in 1 ml VOLUME 1 ml MAX DOSE 10 ml (4,000 micrograms) ``` Cardiac arrest (where opioid toxicity is considered to be the likely cause) Route: Intravenous/intraosseous In cardiac arrest, children or adults, repeat up to maximum dose until ROSC achieved. AGE >12 years INITIAL DOSE 400 micrograms REPEAT DOSE 800 micrograms DOSE INTERVAL 1 minute CONCENTRATION 400 micrograms in 1 ml VOLUME 1 ml MAX DOSE 10,000 micrograms ``` Respiratory arrest/respiratory depression due to opiate overdose (End of Life) Route: Intravenous/intraosseous, intramuscular/subcutaneous, intranasal Only consider if respiratory rate <8 breaths per minute, unconscious, or cyanosed due to opiate overdose. Consider seeking senior clinical advice. AGE Adult ≥12 years INITIAL DOSE 200 micrograms REPEAT DOSE 200 micrograms DOSE INTERVAL 3 minutes CONCENTRATION 400 micrograms in 1 ml VOLUME 0.5 ml MAX DOSE 4,000 micrograms

Answer 140

Moderate to severe pain. | Labour pains.

Answer 141

Inhaled analgesic agent.

Answer 142

Nitrous oxide may have a deleterious effect if administered to patients with closed body cavities containing air since nitrous oxide diffuses into such a space with a resulting increase in pressure. Do not give nitrous oxide to patients with: Severe head injuries with impaired consciousness due to possible presence of intracranial air. Decompression sickness (the bends) where nitrous oxide can cause nitrogen bubbles within the blood stream to expand, aggravating the problem further. Consider anyone that has been diving within the previous 24 hours to be at risk. Violently disturbed psychiatric patients. An intraocular injection of gas within the last eight weeks. Check to see if these patients have an information leaflet, card or wristband. The information leaflet may advise that nitrous oxide can be administered less than eight weeks after intraocular injection of gas. Abdominal pain where intestinal obstruction is suspected.

Answer 143

Any patient at risk of having a pneumothorax, pneumomediastinum and/or a pneumoperitoneum (e.g. polytrauma, penetrating torso injury).

Answer 144

Minimal side effects.

Answer 145

Prolonged use for more than 24 hours, or more frequently than every four days, can lead to vitamin B12 deficiency. Administration of nitrous oxide should be in conjunction with pain score monitoring. Advantages of nitrous oxide include: Rapid analgesic effect with minimal side effects. No cardiorespiratory depression. Self-administered. Analgesic effect rapidly wears off. The 50% oxygen concentration is valuable in many medical and trauma conditions. Nitrous oxide can be administered whilst preparing to deliver other analgesics. The usual precautions must be followed with regard to caring for the Entonox® equipment and the cylinder MUST be inverted several times before use to mix the gases when temperatures are low. EEAST Spefici: ENTONOX cylinders in cold weather Entonox is a widely used analgesic mixture of equal parts oxygen and nitrous oxide, stored in a pressurised cylinder. The Trust’s medical gas stores are often located outside or in garages where the temperature may fall below – 6°C. There is therefore a risk of the gases dissociating, leading to the risk of the patient not receiving the 50/50 mix, but up to 100% N2O, resulting in the onset of anaesthesia. It is important to understand the difference between safe storage conditions to prevent separation, and the revaporisation procedure once separation may have occurred. There is no risk of separation in stored, full cylinders unless the ambient temperature falls to below – 6°C. There have been no reported incidents of delivery of a hypoxic mixture during cold winters in the East of England. Key issues: Identify when gaseous separation may have occurred (only a risk below – 6°C). Ensure revapourization if it is possible separation has occurred (either warm in water for five minutes or keep > 10°C for more than 24 hours). Cylinders that have not fallen below – 6°C are not at risk of separation and therefore do not need immersion/storage at > 10°C. Actions – all Trust clinicians 1 Cylinders taken from medical gas stores where the temperature is likely to have fallen below – 6°C in the previous 24 hours are at risk of dissociation and must be placed in warm water (not hot) for five minutes and inverted three times, prior to placing them on a vehicle or in any other clinical area. Do not submerse the cylinder valve. 2 All cylinders on vehicles or in other clinical areas should be maintained at a temperature above 10°C. This may necessitate cylinders (including spares) being kept in warm areas of buildings when vehicles are non-operational. Make sure that if you remove Entonox cylinders to keep them warm then there is a clear message left for the next crew to prompt them to replace the cylinders. 3 Operational vehicles should be able to maintain an internal temperature of above 10°C, even while on cover. However, staff should be aware that the vehicle cylinder stores may become very cold when on standby. If the external temperature falls to less than – 6°C then all Entonox cylinders should be taken inside to be kept warm (including spares). Don’t forget to put them back on the vehicle when dispatched. 4 Entonox cylinders should be routinely agitated and inverted three times before use during any period of cold weather. BOC’s official advice is as follows: Nitrous oxide begins to separate out from Entonox if the temperature falls below about – 6°C. A homogenous mixture is again obtained when the temperature is raised to above 10°C and the cylinder agitated. Before use, to ensure it is properly mixed, cylinders should be stored horizontally for 24 hours at a temperature above 10°C. If this is not practicable, before use the cylinders must be maintained at a temperature above 10°C for at least two hours and then completely inverted three times or placed in warm water at body temperature for five minutes and then completely inverted three times.

Answer 146

Adults: Nitrous oxide should be self-administered via a facemask or mouthpiece, after suitable instruction. It takes about 3–5 minutes to be effective, but it may be 5–10 minutes before maximum effect is achieved. Children: Nitrous oxide is effective in children provided they are capable of following the administration instructions and can activate the demand valve.

Answer 147

Adults: Prevention and treatment of opiate-induced nausea and vomiting (e.g. morphine sulphate). Treatment of nausea or vomiting. Children: Prevention and treatment of opiate-induced nausea and vomiting (e.g. morphine sulphate). For travel associated nausea or vomiting.

Answer 148

An anti-emetic that blocks 5HT receptors both centrally and in the gastrointestinal tract.

Answer 149

Known sensitivity to ondansetron. | Infants <1 month old.

Answer 150

QT interval prolongation (avoid concomitant administration of drugs that prolong QT interval). Hepatic impairment. Pregnancy. Breastfeeding.

Answer 151

``` Hiccups. Constipation. Flushing. Hypotension. Chest pain. Arrhythmias. Bradycardia. Headache. Seizures. Movement disorders. Injection site reactions. ```

Answer 152

Ondansetron should always be given in a separate syringe to morphine sulphate – the drugs must NOT be mixed. Ondansetron should NOT be routinely administered in the management of childhood gastroenteritis (refer to Paediatric Gastroenteritis). Vomiting can be a symptom of a more serious problem. If a patient is sufficiently unwell that they require parenteral anti-emetics, the Paramedic must seek further advice from a specialist or a GP before making the decision to leave them on scene with Ondansetron.

Answer 153

Note: Two preparations exist (4 mg in 2 ml and 8 mg in 4 ml). They share the same concentration, that is 2 milligrams in 1 ml. Route: Intravenous (SLOW IV injection over 2 minutes)/intramuscular. AGE ≥ 12 years INITIAL DOSE 4 milligrams REPEAT DOSE NONE DOSE INTERVAL N/A CONCENTRATION 2 milligrams in 1 ml VOLUME 2 ml MAX DOSE 4 milligrams NB Monitor pulse, blood pressure, respiratory rate and cardiac rhythm before, during and after administration.

Answer 154

Children Significant illness and/or injury. Adults Critical illnesses requiring high levels of supplemental oxygen (refer to Table 7.5). Serious illnesses requiring moderate levels of supplemental oxygen if the patient is hypoxaemic (refer to Table 7.6). COPD and other conditions requiring controlled or low-dose oxygen therapy (refer to Table 7.7). Conditions for which patients should be monitored closely but oxygen therapy is not required unless the patient is hypoxaemic (refer to Table 7.8).

Answer 155

Essential for cell metabolism. Adequate tissue oxygenation is essential for normal physiological function. Oxygen assists in reversing hypoxia, by raising the concentration of inspired oxygen. Hypoxia will, however, only improve if respiratory effort or ventilation and tissue perfusion are adequate. If ventilation is inadequate or absent, assisting or completely taking over the patient's ventilation is essential to reverse hypoxia.

Answer 156

Explosive environments.

Answer 157

Oxygen increases the fire hazard at the scene of an incident. Defibrillation – ensure pads firmly applied to reduce spark hazard.

Answer 158

Non-humidified O2 is drying and irritating to mucous membranes over a period of time. In patients with COPD there is a risk that even moderately high doses of inspired oxygen can produce increased carbon dioxide levels which may cause respiratory depression and this may lead to respiratory arrest. Refer to Table 7.7 for guidance.

Answer 159

Measure oxygen saturation (SpO2) in all patients using pulse oximetry. For the administration of moderate levels of supplemented oxygen nasal cannulae are recommended in preference to a simple face mask as they offer a more flexible dose range. Patients with tracheostomy or previous laryngectomy may require alternative appliances (e.g. tracheostomy masks). Entonox may be administered when required. Document oxygen administration. Children ALL children with significant illness and/or injury should receive HIGH levels of supplementary oxygen. Adults Administer the initial oxygen dose until a reliable oxygen saturation reading is obtained. If the desired oxygen saturation cannot be maintained with a simple face mask, change to a high concentration oxygen mask. For dosage and administration of supplemental oxygen refer to Table 7.5–Table 7.8. For conditions where NO supplemental oxygen is required unless the patient is hypoxaemic refer to Table 7.8. BTS guidance states that a sudden reduction of more than 3% in a patient’s oxygen saturation within the target saturation range should prompt fuller assessment of the patient because this may be the first evidence of an acute illness. Some people aged above 70 years may have saturation measurements in the range of 92–94% when clinically stable. These people do not require oxygen therapy unless the oxygen saturation falls below the level that is known to be normal for the individual patient.

Answer 160

Oral Relief of mild to moderate pain or high temperature with discomfort (not for high temperature alone). Intravenous As part of a balanced analgesic regimen for severe pain paracetamol is effective in reducing opioid requirements while improving analgesic efficacy and is an alternative analgesic when morphine is contraindicated.

Answer 161

Analgesic (pain relieving) and antipyretic (temperature reducing) drug.

Answer 162

Known paracetamol allergy. Do NOT give further paracetamol if a paracetamol–containing product (e.g. Calpol, co-codamol) has already been given within the last 4 hours (6 hours in patients with renal impairment) or if the maximum cumulative daily dose has already been given.

Answer 163

Take care when administering paracetamol injection to avoid dosing errors due to confusion between milligram (mg) and millilitre (mL), which could result in accidental overdose and death. Before administering, check when paracetamol was last administered and the cumulative paracetamol dose over the previous 24 hours. The intravenous preparations come in different sizes, and due to the small amounts that are recommended for children from birth upwards, and for patients that weigh less than 50kg, extreme vigilance is needed. Refer to local procedure and guidance on how to administer dependant on what preparations are available to you.

Answer 164

Side effects are extremely rare; occasionally intravenous paracetamol may cause hypotension if administered too rapidly.

Answer 165

A febrile child should always be conveyed to hospital except where: a full assessment has been carried out, and the child has no apparent serious underlying illness, and the child has a defined clinical pathway for reassessment and follow up, with the full consent of the parent (or carer). Paracetamol injection is supplied in plastic and glass containers. If a glass container is used it should be remembered that close monitoring is needed at the end of the infusion to avoid air embolism.

Answer 166

Route: Oral – tablet. Ensure that: Paracetamol (or an alternative paracetamol-containing product) has not been taken within the previous 4 hours (6 hours in renal impairment). The maximum cumulative daily dose has not already been taken. Route: Intravenous infusion; given over 15 minutes. Ensure that: Paracetamol (or an alternative paracetamol-containing product) has not been taken within the previous 4 hours (6 hours in renal impairment). The maximum cumulative daily dose has not already been taken. IV paracetamol is only used when managing severe pain (use an oral preparation when managing fever with discomfort).

Answer 167

Acute asthma attack where normal inhaler therapy has failed to relieve symptoms. Expiratory wheezing associated with allergy, anaphylaxis, beta-blocker overdose, smoke inhalation or other lower airway cause. Exacerbation of chronic obstructive pulmonary disease (COPD).

Answer 168

Salbutamol is a selective beta2 adrenoreceptor stimulant drug. This has a relaxant effect on the smooth muscle in the medium and smaller airways, which are in spasm in acute asthma attacks. If given by nebuliser, especially if oxygen powered, its smooth-muscle relaxing action, combined with the airway moistening effect of nebulisation, can relieve the attack rapidly.

Answer 169

None in the emergency situation.

Answer 170

Salbutamol should be used with care in patients with: Hypertension Angina Overactive thyroid Late pregnancy (can relax uterus) Bronchomalacia / laryngomalacia / tracheomalacia (abnormal softening of the bronchial tubes, larynx and trachea) Severe hypertension may occur in patients on beta-blockers and half doses should be used unless there is profound hypotension. If COPD is a possibility limit nebulisation with oxygen to 6 minutes.

Answer 171

``` Tremor (shaking). Tachycardia. Palpitations. Headache. Feeling of tension. Peripheral vasodilatation. Muscle cramps. Rash. ```

Answer 172

In acute severe or life-threatening asthma ipratropium should be given after the first dose of salbutamol. In acute asthma or COPD unresponsive to salbutamol alone, a single dose of ipratropium may be given after salbutamol. Salbutamol often provides initial relief. In more severe attacks, however, the use of steroids by injection or orally and further nebuliser therapy will be required. Do not be lulled into a false sense of security by an initial improvement after salbutamol nebulisation. Nebules should be protected from light after removal from the foil overwrap pouch. They should be disposed of after a reduced period of expiry, indicated on the pouch. Salbutamol is not indicated in bronchiolitis. It will not benefit the condition and the resultant tachycardia may confuse subsequent clinical assessment in hospital.

Answer 173

In life-threatening or acute severe asthma: undertake a TIME CRITICAL transfer to the NEAREST SUITABLE RECEIVING HOSPITAL and provide nebulisation en-route. If COPD is a possibility limit nebulisation with oxygen to 6 minutes. The pulse rate in children may exceed 140 after significant doses of salbutamol; this is not usually of any clinical significance and should not usually preclude further use of the drug. Repeat doses should be discontinued if the side effects are becoming significant (e.g. tremors, tachycardia >140 beats per minute in adults) – this is a clinical decision by the ambulance clinician. ``` Route: Nebulised with 6–8 litres per minute of oxygen. AGE Adult INITIAL DOSE 5 milligrams REPEAT DOSE 5 milligrams DOSE INTERVAL 5 minutes CONCENTRATION 2.5 milligrams in 2.5 ml VOLUME 5 ml MAX DOSE No limit ```

Answer 174

``` Adult fluid therapy: Medical conditions without haemorrhage. Medical conditions with haemorrhage. Trauma related haemorrhage. Burns. Limb crush injury. ``` Child fluid therapy: Medical conditions. Trauma related haemorrhage. Burns. Flush: As a flush to confirm patency of an intravenous or intraosseous cannula. As a flush following drug administration.

Answer 175

Increases vascular fluid volume which consequently raises cardiac output and improves perfusion.

Answer 176

Soduim Chloride should NOT be administered solely for the purposes of keeping a vein open (TKO/TKVO) as this may lead to inadvertent excess fluid administration.

Answer 177

Over-infusion may precipitate pulmonary oedema and cause breathlessness.

Answer 178

Fluid replacement in cases of dehydration should occur over hours; rapid fluid replacement is seldom indicated; refer to Intravascular Fluid Therapy in Adults and Intravascular Fluid Therapy in Children. EEAST Specific: Frequency Adults — monitor physiological response: re-assess perfusion, pulse, respiratory rate and blood pressure whenever possible. If these observations improve, slow the infusion rate. If no improvement administer further 250ml boluses (maximum 2 litres) Adults in hypovolaemia: If the patient remains hypotensive despite repeated 250 ml boluses AND the patient is trapped on scene, request on line clinical support. Excessive rise of blood pressure may cause re-bleeding and further haemorrhage. Aim to maintain a systolic blood pressure of 90mmHg, measured accurately where possible or estimated by the presence of a radial pulse where time is critical. Children — hypovolaemia: If necessary a further dose of up to 20ml/kg may be administered as above. If still hypovolaemic seek on line help. Children — in hyperglycaemia: Generally emergency IV fluids should be minimised or avoided because of serious side effects that may occur.

Answer 179

``` Route: Intravenous or intraosseous for ALL conditions. FLUSH AGE Adult INITIAL DOSE 2 ml – 5 ml REPEAT DOSE 2 ml – 5 ml DOSE INTERVAL PRN CONCENTRATION 0.90% VOLUME 2 – 5 ml MAX DOSE N/A ``` ``` FLUSH AGE Adult INITIAL DOSE 10 ml – 20 ml (if infusing glucose) REPEAT DOSE 10 ml – 20 ml (if infusing glucose) DOSE INTERVAL PRN CONCENTRATION 0.90% VOLUME 10 – 20 ml MAX DOSE N/A ``` ADULT MEDICAL EMERGENCIES General medical conditions without haemorrhage For anaphylaxis, seek senior clinical advice if more than 2 litres is required. INITIAL DOSE 250 ml Sepsis: Clinical signs of infection AND systolic BP<90 mmHg INITIAL DOSE 500 ml ``` Diabetic Ketoacidosis (DKA) INITIAL DOSE 500 ml ``` Medical conditions with haemorrhage: Systolic BP<90 mmHg and signs of poor perfusion INITIAL DOSE 250 ml ADULT TRAUMA EMERGENCIES Blunt trauma, head trauma or penetrating limb trauma: The general aim of fluid therapy is to maintain a palpable peripheral pulse (radial) OR systolic BP of 90mmHg. INITIAL DOSE 250 ml Penetrating torso trauma: The general aim of fluid therapy is to maintain a palpable central pulse (carotid) OR a systolic BP of 60 mmHg INITIAL DOSE 250 ml Burns Total body surface area (TBSA): Between 15% and 25% and time to hospital is greater than 30 minutes TBSA: More than 25% INITIAL DOSE 250 ml Crush syndrome NB Manage crush injury of the torso as per blunt trauma INITIAL DOSE 2 litres MEDICAL EMERGENCIES IN CHILDREN (20 ml/kg) NB Exceptions: Cardiac failure, renal failure, diabetic ketoacidosis without shock (see Medical Emergencies in Children Diabetic Ketoacidosis dosage table) MEDICAL EMERGENCIES IN CHILDREN Heart failure or renal failure (10 ml/kg) MEDICAL EMERGENCIES IN CHILDREN Diabetic ketoacidosis where patient is dehydrated but NOT shocked, (10 ml/kg) administer ONCE only over 30 minutes TRAUMA EMERGENCIES IN CHILDREN (5 ml/kg)1Seek advice to exceed maximum dose in trauma NB Exceptions: Burns Burns (10 ml/kg, given over 1 hour) TBSA: Between 10% and 20% and time to hospital is greater than 30 minutes TBSA: More than 20%

Answer 180

Blood and fluid loss, to correct hypovolaemia and improve tissue perfusion if sodium chloride 0.9% is NOT available. Dehydration.

Answer 181

Increases vascular fluid volume which consequently raises cardiac output and improves perfusion.

Answer 182

Diabetic hyperglycaemic ketoacidotic coma, and precoma. NB Administer 0.9% sodium chloride intravenous infusion. Neonates.

Answer 183

Sodium lactate should not be used in limb crush injury when 0.9% sodium chloride is available. Renal failure. Liver failure.

Answer 184

Infusion of an excessive volume may overload the circulation and precipitate heart failure (increased breathlessness, wheezing and distended neck veins). Volume overload is unlikely if the patient is correctly assessed initially and it is very unlikely indeed if patient response is assessed after initial 250 ml infusion and then after each 250 ml of infusion. If there is evidence of this complication, the patient should be transported rapidly to nearest suitable receiving hospital whilst administering high-flow oxygen. Do not administer further fluid.

Answer 185

250 ml, 500 ml and 1,000 ml packs of compound sodium lactate intravenous infusion (also called Hartmann's solution for injection or Ringer's lactate solution for injection). Compound sodium lactate intravenous infusion contains mainly sodium, but also small amounts of potassium and lactate. It is useful for initial fluid replacement in cases of blood loss. The volume of compound sodium lactate intravenous infusion needed is 3 times as great as the volume of blood loss. Sodium lactate has NO oxygen carrying capacity.

Answer 186

Route: Intravenous or intraosseous for ALL conditions. ADULT MEDICAL EMERGENCIES General medical conditions without haemorrhage: anaphylaxis, dehydration. In cases of dehydration fluid replacement should usually occur over hours. AGE Adult INITIAL DOSE 250 ml REPEAT DOSE 250 ml DOSE INTERVAL PRN CONCENTRATION Compound VOLUME 250 ml MAX DOSE 1 litre NB Exception sodium lactate compound is contra-indicated in diabetic ketoacidosis – refer to Sodium Chloride 0.9%. Sepsis: Clinical signs of infection AND systolic BP<90 mmHg AND tachypnoea INITIAL DOSE 1 litre ADULT TRAUMA EMERGENCIES Medical conditions with haemorrhage: Systolic BP<90 mmHg and signs of poor perfusion INITIAL DOSE 250 ml Blunt trauma, head trauma or penetrating limb trauma: Systolic BP<90 mmHg and signs of poor perfusion INITIAL DOSE 250 ml Penetrating torso trauma: Systolic BP<60 mmHg and signs of poor perfusion INITIAL DOSE 250 ml Burns: TBSA: between 15% and 25% and time to hospital is greater than 30 minutes. TBSA: more than 25%. INITIAL DOSE 1 litre Limb crush injury NB Sodium chloride 0.9% is the fluid of choice in crush injury. NB Manage crush injury of the torso as per blunt trauma. INITIAL DOSE 2 litres MEDICAL EMERGENCIES IN CHILDREN (20 ml/kg) – NB Exceptions heart failure, renal failure, liver failure, diabetic ketoacidosis (sodium lactate compound is contra-indicated in diabetic ketoacidosis – refer to Sodium Chloride 0.9%. MEDICAL EMERGENCIES IN CHILDREN Heart failure or renal failure (10 ml/kg) TRAUMA EMERGENCIES IN CHILDREN (5 ml/kg) NB Exceptions: burns. Burns (10 ml/kg, given over 1 hour): TBSA: between 10% and 20% and time to hospital is greater than 30 minutes. TBSA: more than 20%.

Answer 187

Post-partum haemorrhage within 24 hours of delivery of the infant where bleeding from the uterus is uncontrollable by uterine massage. Miscarriage with life-threatening bleeding and a confirmed diagnosis (e.g. where a patient has gone home with medical management and starts to bleed).

Answer 188

Stimulates contraction of the uterus. Onset of action 7–10 minutes.

Answer 189

Known hypersensitivity to syntometrine. In labour, prior to the birth of the baby. Severe cardiac, liver or kidney disease. Hypertension and severe pre-eclampsia. Possible multiple pregnancy/known or suspected fetus in utero.

Answer 190

Nausea and vomiting. Abdominal pain. Headache. Hypertension and bradycardia. Chest pain and, rarely, anaphylactic reactions.

Answer 191

Syntometrine and misoprostol reduce bleeding from a pregnant uterus through different pathways; therefore if one drug has not been effective after 15 minutes, the other may be administered in addition.

Answer 192

Route: Intramuscular. AGE Adult INITIAL DOSE 500 micrograms of ergometrine and 5 units of oxytocin REPEAT DOSE None DOSE INTERVAL N/A CONCENTRATION 500 micrograms of ergometrine and 5 units of oxytocin in 1 ml VOLUME 1 ml MAX DOSE 500 micrograms of ergometrine and 5 units of oxytocin

Answer 193

Acute ST segment elevation MI (STEMI) within 6 hours of symptom onset where primary percutaneous coronary intervention (PPCI) is NOT readily available. Ensure patient fulfils the criteria for drug administration following the model checklist (below). Variation of these criteria is justifiable at local level with agreement of appropriate key stakeholders (e.g. cardiac network, or in the context of an approved clinical trial).

Answer 194

Is primary PCI available? YES – undertake a TIME CRITICAL transfer to PPCI capable hospital. NO – ask the patient the questions listed below, to determine whether they are suitable to receive thrombolysis. Assessment Questions: YES/NO Has the patient suffered a haemorrhagic stroke or stroke of unknown origin at any time? Has the patient suffered a transient ischaemic attack in the preceding 6 months? Has the patient suffered a central nervous system trauma or neoplasm? Has the patient had recent trauma, surgery, or head injury within the preceding 3 weeks? Has the patient suffered from gastrointestinal bleeding (within the last month)? Has the patient a known bleeding disorder? Do you suspect aortic dissection? Has the patient a non-compressible puncture (e.g. liver biopsy, lumbar puncture)? Is the patient taking oral anticoagulant therapy (e.g. warfarin)? Is the patient pregnant or within 1 week post-partum? Is the patient's systolic blood pressure >180 mmHg and/or diastolic blood pressure >110 mmHg? Is the patient suffering from advanced liver disease? Is the patient suffering from active peptic ulcer? If the patient answers YES TO ANY of the above questions, thrombolysis IS NOT indicated; seek advice. If the patient answers NO TO ALL of the above questions and thrombolysis is indicated, refer to the dosage and administration table.

Answer 195

Activates the fibrinolytic system, inducing the breaking up of intravascular thrombi and emboli.

Answer 196

Bleeding: Major – seek medical advice and transport to hospital rapidly. Minor (e.g. at injection sites) – use local pressure. Arrhythmias – these are usually benign in the form of transient idioventricular rhythms and usually require no special treatment. Treat ventricular fibrillation (VF) as a complication of myocardial infarction (MI) with standard protocols; bradycardia with atropine as required. Anaphylaxis – extremely rare (0.1%) with third generation bolus agents. Hypotension – often responds to laying the patient flat.

Answer 197

PPCI is now the dominant reperfusion treatment and should be used where available; patients with STEMI will be taken direct to a specialist cardiac centre instead of receiving thrombolysis (refer to Acute Coronary Syndrome). Local guidelines should be followed. ‘Time is muscle!’ Do not delay transportation to hospital if difficulties arise whilst setting up the equipment or establishing IV access. Qualified single responders should administer a thrombolytic if indicated while awaiting arrival of an ambulance.

Answer 198

Ensure a defibrillator is immediately available at all times. Monitor conscious level, pulse, blood pressure and cardiac rhythm during and following injections. Manage complications (associated with the acute MI) as they occur using standard protocols. The main early adverse event associated with thrombolysis is bleeding, which should be managed according to standard guidelines. AT HOSPITAL – emphasise the need to commence a heparin infusion in accordance with local guidelines – to reduce the risk of re-infarction.

Answer 199

Weight dependent, see JRCALC. 1 Administer a bolus of intravenous injection of un-fractionated heparin before administration of tenecteplase (refer to Heparin (Unfractionated)). Flush the cannula well with saline. 2 AT HOSPITAL – It is essential that the care of the patient is handed over as soon as possible to a member of hospital staff qualified to administer a heparin infusion. 3 Consider halving the dose in patients aged 75 or over to reduce the risk of intracranial haemorrhage. This will be determined by local pathways. Route: Intravenous single bolus adjusted for patient weight.

Answer 200

Indication | Tranexamic acid is an anti-fibrinolytic which reduces the breakdown of blood clot.

Answer 201

Injured patients from birth onwards with TIME CRITICAL injury where significant internal/external haemorrhage is suspected. Must be administered within 3 hours of injury. Post-Partum Haemorrhage (PPH within 3 hours of delivery and where the patient is still actively haemorrhaging).

Answer 202

Isolated head injury Critical intervention required, i.e. if critical interventions leave insufficient time for administration of tranexamic acid. Bleeding now stopped Known allergy to tranexamic acid Injury occurred more than 3 hours prior to treatment

Answer 203

Rapid injection might rarely cause hypotension There is good data that this treatment is safe and effective (giving a 9% reduction in the number of deaths in patients in the CRASH2 trial). There is no evidence about whether or not tranexamic acid is effective in patients with head injury; however, there is no evidence of harm. No evidence of harm in pregnancy

Answer 204

Contact the Ambulance Trust Clinical Advice line. Ensure medical records detail the advice given and the actions of the patient (including guardian or relative). Seek advice from a medical practitioner.

Answer 205

Contact the Ambulance Trust Clinical Advice line. Ensure medical records detail the advice given and the actions of the patient (including guardian or relative). Seek advice from a medical practitioner.

Answer 206

Name, form and strength of medicine: Ampoule containing 500mg Tranexamic Acid in 5ml (100 mg/ml) Route/method: Intravenous (bolus) Intraosseous (off-license use) ``` Dosage Adults and children ≥12 years Initial Dose 1 gram Repeat Dose NONE Concentration 100mg/ml Volume 10mls Maximum Dose 1 gram ``` Administer SLOWLY as an IV BOLUS over 1–2 minutes. Give a 20ml flush after administration and monitor blood pressure carefully for possible hypotensive response giving appropriate fluid challenges where necessary to maintain perfusion pressure. Children <12years Dose volume diluted in Sodium Chloride 0.9% to a total volume of 20ml and administer SLOWLY over 10 minutes. (e.g. 6 years, draw up 3ml of TXA, add 17ml of NaCl to make 20ml total volume)

Answer 207

Rapid injection might rarely cause hypotension Nausea, vomiting and diarrhoea Possible visual disturbances including visual impairment, vision blurred, impaired colour vision Reporting of adverse effects Use the Yellow Card System to report adverse drug reactions directly to the CSM. Guidance on its use is available at the back of the BNF or can be accessed via the website. http://yellowcard.mhra.gov.uk/ If reported a Trust Datix Report must also be completed.