Medicines Flashcards
Before administering any medication check the:
Type (what is it?) Strength Integrity of the packaging Clarity of the fluid Expiry date
Select the most appropriate route, taking into account:
The patients condition
The urgency of the situation
Only administer drugs via routes you have been trained for.
The drug codes are provided for information only.
Complete documentation.
Activated Charcoal
ACT
Indications
Indications:
The emergency treatment of acute oral poisoning and oral drug overdose.
Adults and children aged 1 and over who have ingested toxins less than 1 hour before attendance by an ambulance clinician.
OR
Adults and children, irrespective of time of ingestion, who have ingested toxins and where Toxbase or the National Poisons Information Service have been contacted and advised the administration of activated charcoal.
NB Toxbase and the NPIS advice cannot overrule exclusion criteria except in relation to time and age.
Paracetamol overdose:
The recommended dose of paracetamol is 4 g (or 75 mg/kg) in 24 hours for an adult patient.
Any ingestion exceeding this is regarded as an overdose. However, toxicity is extremely unlikely if <75 mg/kg paracetamol has been ingested within a 24-hour period.
Single acute overdose is defined as an ingestion of >4 g (or >75 mg/kg) in a period of <1 hour.
The National Poisons Information Service (NPIS) in the UK recommends that, for the purposes of calculating potentially toxic doses, the following be considered:
- For pregnant patients, the toxic dose is calculated using the patient’s pre-pregnancy weight.
- For patients weighing >110. kg, the toxic dose should be calculated using a maximum of 110. kg instead of the patient’s actual weight.
Activated Charcoal
ACT
Contra-Indications
Children under 1 year.
Patients presenting to the ambulance clinician more than 1 hour since ingestion of toxin.
Administration not advised following communication from Toxbase or the NPIS.
Patients who are vomiting.
Patients with reduced gastro-intestinal motility (with a risk of obstruction), i.e. patients taking opioid medication or patients who have recently had abdominal surgery.
Poisoning known to be due to the ingestion of:
- Cyanide
- Petroleum distillates
- Metal salts including salts of lithium and iron
- Ethanol, methanol, ethylene glycol, iron salts, sodium chloride, lead boric acid, other mineral acid
- Malathion
- Corrosive substances (limited usefulness and hinders the visualisation of oesophageal burns or erosions).
Activated Charcoal
ACT
Cautions
Precautions should be taken to prevent aspiration,especially in small children.
Activated charcoal will reduce the effectiveness of other antidotes.
Patients who have taken an overdose and have also consumed recreational alcohol can be administered activated charcoal providing that they are alert enough to safely swallow the charcoal.
Shake the bottle vigorously before administration.
Activated Charcoal
ACT
Side Effects
Black stools.
Intestinal obstruction (blockage of digestive system).
Bezoar formation (ball of material in the stomach that is not passed out).
Intestinal perforation (rare, but can occur after several treatments).
Activated Charcoal
ACT
Dosage and Administration
Route: Oral.
Administer as soon as possible after ingestion or suspected ingestion of the potential poison.
For adults, give a single dose of 50 grams (250 ml) of activated charcoal, as soon as possible after ingestion or suspected ingestion of the potential poison.
For children aged 1 year to under 12 years, encourage the child to drink 125 ml, equivalent to 25 grams of activated charcoal or half of the contents of one bottle, unless a large quantity of poison has been ingested, and where there is a risk to life. In these circumstances, the administration of the full 50 grams dose is indicated.
May be mixed with soft drinks or fruit juice to mask the flavour. However, ice-cream or other foods should not be used as a vehicle for the administration of activated charcoal as they reduce the adsorptive capacity of the activated charcoal.
NOTE Concentration is only applicable to ready-made suspension. If a large quantity of poison has been ingested, and where there is a risk to life, encourage the child to drink the full dose
Adrenaline 1 milligram in 10 ml (1 in 10,000)
ADX
Presentation
Pre-filled syringe containing 1 milligram of adrenaline (epinephrine) in 10 ml (1:10,000) ADX.
Adrenaline 1 milligram in 10 ml (1 in 10,000)
ADX
Indication
Cardiac arrest
Adrenaline 1 milligram in 10 ml (1 in 10,000)
ADX
Actions
Adrenaline is a sympathomimetic that stimulates both alpha- and beta-adrenergic receptors. As a result myocardial and cerebral blood flow is enhanced during CPR and CPR becomes more effective due to increased peripheral resistance which improves perfusion pressures.
Adrenaline 1 milligram in 10 ml (1 in 10,000)
ADX
Cautions
Severe hypertension may occur in patients on non-cardioselective beta-blockers (e.g. propranolol).
Do NOT administer adrenaline when the patient’s core temperature is less than 30˚C.
When the patient’s temperature is between 30˚C and 35˚C, double the time period between doses.
Adrenaline 1 milligram in 10 ml (1 in 10,000)
ADX
Dosage and Administration
Cardiac arrest:
Shockable rhythms: administer adrenaline after the 3rd shock and then after alternate shocks (i.e. 5th, 7th etc).
Non-shockable rhythms: administer adrenaline immediately IV access is achieved then alternate loops.
Route: Intravenous/intraosseous – administer as a rapid bolus.
Adrenaline 1:100,000 Post ROSC Hypotension - Medicines Use Guidance
Indication
Management and treatment regime of post ROSC uncorrected hypotension.
UNDER THE GUIDANCE AND PERMISSION OF THE CLINICAL ADVICE LINE (CAL) 01234 779203:
Post ROSC patients where fluid boluses (up to 1000mls) have failed to correct hypotension (<90mmHg systolic).
Must be post ROSC!
Must have tried fluid boluses as a first line treatment. All adult patients including those with pulmonary oedema including cardiogenic shock should be able to receive up to 1000mls 0.9% NaCl. If not responsive to fluid resuscitation, this could be an indication that Adrenaline would be of benefit∙ Rule out bradycardia as a source of low cardiac output. Any bradycardia should have been attempted to be resolved with O2 and atropine up to 3 mg. This may negate the need for adrenaline once heart rate goes up.
Absolute bradycardia (3rd degree block) won’t respond to atropine and adrenaline may assist raising BP showing one or more of the 4 adverse features as per RC(UK) bradycardia algorithm. Ultimately these pts need pacing. Refer to CCD or expedite transport to ED/PPCI as appropriate.
Adults only. Paediatric dosing for this is complicated as such administration of inotropic support in children is to be avoided.
Ensure full monitoring is applied and confirm BP readings are auto-cycling every 2 mins on the Corpuls and pay close attention for manifestation of arrhythmias.
10-20mcgs at a time depending on initial reaction to administration. Post ROSC vasoconstrictor support is ideally done via an IV infusion providing steady and constant flow. Essentially we are trying to replicate that with low dose frequent boluses. Infusion rates are normally 2-10mcgs per min so depending on effect, 10-20 mcgs every 3-5 mins will be safe but could cause spikes and dips in BP that may be missed with NIBP readings. Any administration of Adrenaline as a vasoconstrictor should be done with extreme caution.
Drawing up can be done in several ways. Easiest is via a 3-way tap. Put empty syringe and the adrenaline each on one of the ‘giving’ ports, close off the end that would otherwise be attached to the patient and then draw it through. Alternatively they could use an IM needle to draw directly through the hole in the end of the adrenaline syringe. The red drawing up needles don’t fit. This is more risky as it brings more sharps in to play but in the absence of a 3-way tap is manageable.
Adrenaline 1:100,000 Post ROSC Hypotension - Medicines Use Guidance
Contra-indication
<18 years of age
BP >90mmHg systolic. At 90mmHg systolic, pressure is sufficient to maintain CPP, ICP and perfusion of kidneys and liver.
Adrenaline 1:100,000 Post ROSC Hypotension - Medicines Use Guidance
Cautions
Heart disease, hypertension, arrhythmias, cerebrovascular disease, elderly patients.
Adrenaline 1:100,000 Post ROSC Hypotension - Medicines Use Guidance
Dosage and Administration
Given IV / IO in 1-2 ml boluses (a dose of 10-20mcg) as necessary to achieve desired effect every 3-5 mins.
To prepare the correct concentration, draw 1ml (100mcg) of 1:10,000 Adrenaline in to a 10ml syringe. This is best achieved by utilising a 3-way tap. Attach the empty syringe to one of administration ports and the Adrenaline to one of the others and draw it through.
Dilute with 9mls NaCl to make a 10ml Adrenaline solution. This will now have 100mcg diluted to 10 mls achieving:
10mcgs per ml
Syringe must then be labelled showing contents and dose per ml.
Dose
1-2 mls, 10-20 mcgs bolus doses.
Frequency
Given every 3-5 mins to achieve and maintain the desired 90mmHg systolic BP.
Duration of Treatment
As required whilst en-route to hospital.
Adrenaline 1:100,000 Post ROSC Hypotension - Medicines Use Guidance
Side effects
Arrhythmias, hypertension, tachycardia, dizziness, palpations, vomiting, dyspnoea, pulmonary oedema, headache, tremor, restlessness.
Adrenaline 1 milligram in 1 ml (1 in 1,000)
ADM
Indications
Anaphylaxis.
Life-threatening asthma with failing ventilation AND continued deterioration despite nebuliser therapy.
Adrenaline 1 milligram in 1 ml (1 in 1,000)
ADM
Actions
Adrenaline is a sympathomimetic that stimulates both alpha- and beta-adrenergic receptors. As a result myocardial and cerebral blood flow is enhanced during CPR and CPR becomes more effective due to increased peripheral resistance which improves perfusion pressures.
Reverses allergic manifestations of acute anaphylaxis.
Relieves bronchospasm in acute severe asthma.
Adrenaline 1 milligram in 1 ml (1 in 1,000)
ADM
Cautions
Severe hypertension may occur in patients on non-cardioselective beta-blockers (e.g. Propranolol).
Do NOT administer IV adrenaline in cases of anaphylaxis.
Adrenaline 1 milligram in 1 ml (1 in 1,000)
ADM
Dosage and Administration
Route: Intramuscular – antero-lateral aspect of thigh.
Amiodarone Hydrochloride
AMO
Indications
Cardiac arrest:
Shockable rhythms: if unresponsive to defibrillation administer amiodarone after the 3rd shock and an additional bolus depending on age to unresponsive VF or pulseless VT following the 5th shock.
EEAST Specific:
Treatment of Broad Complex Tachycardia
Patients who have broad complex tachycardia with a rate greater than 150 / minute and associated signs of cardiovascular compromise which include:
- Reduced conscious level
- Systolic blood pressure <90 mmHg
- Presence of chest pain
- Signs of heart failure
And following agreement from the senior clinician on call on the Clinical Advice Line.
Amiodarone Hydrochloride
AMO
Actions
Antiarrhythmic; lengthens cardiac action potential and therefore effective refractory period. Prolongs QT interval on ECG.
Blocks sodium and potassium channels in cardiac muscle.
Acts to stabilise and reduce electrical irritability of cardiac muscle.
Amiodarone Hydrochloride
AMO
Contra-indications
No contra-indications in the context of the treatment of cardiac arrest.
EEAST Specific:
Cardiac arrest:
All patients not in a cardiac arrest
All patients in cardiac arrest due to a non-shockable rhythm
Tachycardia: Patients below the age 20 Known hypokalaemia Known Pregnancy Known sensitivity to iodine
Amiodarone Hydrochloride
AMO
Side effects
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
Amiodarone Hydrochloride
AMO
Dosage and Administration
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.
Amiodarone Hydrochloride
AMO
Cautions
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.
Aspirin
ASP
Indications
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.
Aspirin
ASP
Actions
Has an antiplatelet action which reduces clot formation.
Aspirin
ASP
Contra-indications
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.
Aspirin
ASP
Cautions
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.
Aspirin
ASP
Side Effects
Increased risk of gastric bleeding.
Wheezing in some asthmatics.
Aspirin
ASP
Additional Information
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%.
Aspirin
ASP
Dosage and Administration
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
Atropine Sulphate
ATR
Indications
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.
Atropine Sulphate
ATR
Contra-indications
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.
Atropine Sulphate
ATR
Actions
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.
Atropine Sulphate
ATR
Side Effects
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.
Atropine Sulphate
ATR
Additional Information
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.
Atropine Sulphate
ATR
Dosage and Administration
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.
Atropine Sulphate
ATR
For CBRN
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).
Benzylpenicillin Sodium
BPN
Indications
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).
Benzylpenicillin Sodium
BPN
Actions
Antibiotic: narrow-spectrum.
Benzylpenicillin Sodium
BPN
Contr-indications
Known severe penicillin allergy (more than a simple rash alone).
Benzylpenicillin Sodium
BPN
Additional Information
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.
Benzylpenicillin Sodium
BPN
Dosage and Administration
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.
Chlorphenamine
CPH
Indication
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.
Chlorphenamine
CPH
Actions
An antihistamine that blocks the effect of histamine released during a hypersensitivity (allergic) reaction.
Chlorphenamine
CPH
Contra-indications
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.
Chlorphenamine
CPH
Cautions
Pregnancy and breastfeeding. Hypotension. Epilepsy. Glaucoma. Severe liver disease.
Chlorphenamine
CPH
Side effects
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.
Chlorphenamine
CPH
Routes and Administration
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.
Ticagrelor
Indications
To: All clinical staff
Date: 25th June 2021
Document number: CI107
Acute STEMI indicated for transfer to PPCI secondary to administration of aspirin.
Ticagrelor
Actions
Inhibits platelet aggregation
Ticagrelor
Contra-indications
Known allergy to ticagrelor
Active bleeding
History of intercranial haemorrhage
Severe hepatic impairment
Ticagrelor
Cautions
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.
Ticagrelor
Side Effects
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
Ticagrelor
Routes and Administration
180mg
2x 90mg tablets dissolved in mouth and swallowed.
Dexamethasone
DEX
Indications
Mild/moderate/severe croup, scored using the Modified Taussig Score, refer to Respiratory Illness in Children.
Dexamethasone
DEX
Actions
Corticosteroid – reduces subglottic inflammation.
Dexamethasone
DEX
Contra-indications
Impending respiratory failure.
Dexamethasone
DEX
Cautions
Upper airway compromise can be worsened by any procedure that distresses the child – this might include the administration of medication.
Dexamethasone
DEX
Side Effects
Gastro-intestinal upset.
Hypersensitivity/anaphylactic reaction.
Dexamethasone
DEX
Additional Information
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.
Dexamethasone
DEX
Dosage and Administration
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.
Diazepam
DZP
Indications
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).
Diazepam
DZP
Actions
Central nervous system depressant, acts as an anticonvulsant and sedative.
Diazepam
DZP
Cautions
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.
Diazepam
DZP
Contra-indications
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.
Diazepam
DZP
Side effects
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.
Diazepam
DZP
Additional information
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.
Diazepam
DZP
Dosage and Administration
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.
Furosemide
FRM
Indications
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)
Furosemide
FRM
Actions
Furosemide is a potent diuretic with a rapid onset (within 30 minutes) and short duration.
Furosemide
FRM
Contra-indications
Reduced GCS with liver cirrhosis.
Cardiogenic shock.
Severe renal failure with anuria.
Children under 18 years old.
Furosemide
FRM
Cautions
Hypokalaemia (low potassium) could induce arrhythmias.
Pregnancy.
Hypotensive patient.
Patient may already be on other diuretics — to continue regular treatment
Furosemide
FRM
Side Effects
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.
Furosemide
FRM
Additional Information
Consider furosemide when the time to get the patient to hospital is prolonged.
Furosemide
FRM
Dosage and Administration
Intravenous
Route: Intravenous
Administer SLOWLY OVER 2 minutes in accordance with the table below.
Glucagon
GLU
Indications
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.
Glucagon
GLU
Actions
Glucagon is a hormone that induces the conversion of glycogen to glucose in the liver, thereby raising blood glucose levels.
Glucagon
GLU
Contra-indications
Pheochromocytoma.
Glucagon should NOT be given by IV injection because of increased vomiting associated with IV use.
Glucagon
GLU
Cautions
Low glycogen stores (e.g. recent use of glucagon or starvation).
For hypoglycaemic seizures, glucose 10% IV is the preferred intervention.
Glucagon
GLU
Side Effects
Nausea, vomiting. Abdominal pain in adults. Diarrhoea in children. Hypokalaemia. Hypotension in adults. Acute hypersensitivity reaction, although this is rare.
Glucagon
GLU
Additional Information
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.
Glucagon
GLU
Dosage and Administration
Intramuscular
Route: Intramuscular – antero-lateral aspect of thigh or upper arm.
Glucose 10%
GLX
Indications
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.
Glucose 10%
GLX
Actions
Reversal of hypoglycaemia by direct delivery of glucose (sugar) to the systemic circulation.
Glucose 10%
GLX
Cautions
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%.
Glucose 10%
GLX
Contra-indications
IM or subcutaneous injection.
Glucose 10%
GLX
Additional Information
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.
Glucose 10%
GLX
Dosage and Administration
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.
Glucose 10%
GLX
Side Effects
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.
