Neuro/Arrest Drugs

Question 1

Presentation of PR Diazepam

Answer 1

Suppository tube containing either 5/10mg in 2.5ml

Question 2

Indications of PR Diazepam

Answer 2

Treatment of Over 1 month olds of:

• Convulsion of over 5 minutes, who are currently seizing where IV access can’t be established
• Repeat convulsions of 3 or more in 1 hour who are currently seizing - not secondary to uncorrected hypoglycaemia or hypoxia - where IV access can’t be established
• Eclamptic convulsion - if the seizure lasts over 2 minutes and persists or is recurrent - where IV access cannot be established

Question 3

Contra-Indications of PR Diazepam

Answer 3

• Known allergy to benzodiazepines
• IV access has been established
• Prior administration of 2 doses of a benzo
• Children under 1 month old
• Children under 1 month (requires CCP intervention)

Be prepared to support ventilations, treat hypotension and monitor for arrythmias especially in the young, old and frail

Question 4

Actions of Diazepam

Answer 4

Diazepam works by acting on GABA receptors in the brain to release the NT GABA. GABA acts as a natural ‘nerve-calming’ agent keeping the nerve activity in the brain in balance by inducing drowsiness, reducing anxiety and relaxing muscles

Question 5

Dose of PR Diazepam

Answer 5

Adults (12-69):
INITIAL DOSE: 20mg***
REPEAT DOSE: 10mg
MAX DOSE: 30mg

Adults (Over 70/frail regardless of age):
INITIAL DOSE: 10mg
REPEAT DOSE: 10mg
MAX DOSE: 20mg
***if IV/IO access is obtained, first dose should be 10mg, max dose of 20mg

Question 6

Presentation of Diazepam Injection

Answer 6

Solution for Injection 10mg in 2ml

Question 7

Indications of Diazepam Injection

Answer 7

• Prolonged convulsions lasting over 5 minutes
• Repeated convulsions of over 3 in 1 hour
• Suspected eclamptic convulsions lasting over 2 minutes where the pt is still convulsing
• Symptomatic cocaine toxicity (severe hypertension, chest pain or convulsions

Question 8

Contra-Indications of Diazepam Injections

Answer 8

• Known allergy to benzo’s
• Where prior administration may exceed the maximal dose
• Presenting with psychogenic cause - follow individualised treatment plane
• Where pt has a specific seizure management plan that doesn’t involve benzo’s
• If the individual is pregnant over 20 weeks, suspect eclamsia and refer to JRCALC pregnancy-induced hypertension guidance

Question 9

Route of Diazepam Injections

Answer 9

Slow IV over 2 minutes (adults)
Slow IV over 3-5 mins (children under 17)
—
Doses may be titrated in symptomatic cocaine toxicity

Answer 10

Adult (Elderly/frail):
INITIAL DOSE: 5mg in 1ml
REPEAT DOSE: 5mg after 10 minutes
MAX DOSE: 10mg

Adult (Normal):
INITIAL: 10mg in 2ml
REPEAT DOSE: 10mg after 10 minutes
MAX DOSE: 20mg

Question 11

Presentation of Buccal Midazolam

Answer 11

An Oro mucosal solution. Pre-filled syringe containing 22.5, 5, 7.5 or 10mg in 5ml

Question 12

Indications of Buccal Midazolam

Answer 12

• Pt who are currently having a prolonged seizure (over 5 minutes) - not secondary to an uncorrected hypoxic/hypoglycaemic episode
• Convuslsion continuing 10 minutes after first dose of medication

Question 13

Contra-Indications of Buccal Midazolam

Answer 13

None in the Emergency Situation

Question 14

Actions of Buccal Midazolam

Answer 14

A short-acting benzodiazepine with anxiolytic, sedative and anticonvulsant properties. Usually starts working within 5 minutes if done buccal. The sedative effect decreases from 15 minutes onwards

Question 15

Route of Buccal Midazolam

Answer 15

Goes between the cheek and teeth - this is called the buccal cavity.

Question 16

How to Administer Buccal Midazolam (Step by Step)

Answer 16

1. Fully remove the cap from the syringe
2. Using your finger and thumb, gently pinch and pull back the patient’s cheek
3. Place the tip of the syringe into the back of the space between the inside cheek and the lower gum
4. Slowly adminster the solution over 4 or 5 seconds. Check whether the dose may need to be divided by two
5. Dispose of the cap and syringe safely

Question 17

Dose Buccal Midazolam

Answer 17

Adult:
INITIAL DOSE: 10mg in 2ml
REPEAT DOSE: 10mg after 10 minutes
MAX DOSE: 20mg

Question 18

Presentation Adrenaline 1:10000

Answer 18

Pre filled 10 ml syringe containing 1mg

Question 19

Indications of Adrenaline 1:10000

Answer 19

• Cardiac arrest - any non-shockable rythms as soon as possible and any shockable ryhthm after 3rd shock
• Post ROSC circulatory support

Question 20

Contra-Indications of Adrenaline 1:10000

Answer 20

• Patient core temp is <30
• Double intervals between 30-35 degrees

Question 21

Actions of Adrenaline 1:10000

Answer 21

• A sympathomimetic that stimulates alpha and beta adrenergic receptors
• As a result myocardial and cerebral blood flow is enhanced during CPR
• CPR becomes more effective due to increased peripheral resistance which improves perfusion pressures

Question 22

Route of Adrenaline 1:10000

Answer 22

IV/IO

Question 23

Intra-Arrest Dose of Adrenaline 1:10000

Answer 23

INITIAL: 1mg in 10ml (1 syringe)

REPEAT: 1mg in 10ml after 3-5 minutes

MAX DOSE: No limit

Question 24

Post ROSC Dose of Adrenaline 1:10000

Answer 24

INITIAL: 50mcg in 0.5ml

REPEAT: 50-100mcg after 3-5 minutes in 0.5-1ml

MAX DOSE: No limit

Question 25

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Presentation of Amiodarone

Answer 25

Pre-filled 10ml syringe of 300mg
Ampuole of 150mg in 3ml

Question 26

Indications of Amiodarone

Answer 26

Shockable rythms after the 3rd and 5th shock

Question 27

Contra-Indications of Amiodarone

Answer 27

Patient core temp is <30

Question 28

Actions of Amiodarone

Answer 28

• Antiarrhythmic - lengthens cardiac action potential and prolongs QT interval
• Blocks sodium and potassium channels in the cardiac muscle
• Stabilises and reduced electrical irritability of cardiac muscle

Question 29

Route of Amiodarone (Note with Adminstration)

Answer 29

IV/IO - large beins can extravastion can cause burns
All doses MUST be flushed with 20ml of saline

Question 30

Dose of Amiodarone

Answer 30

INITIAL: 300mg
REPEAT: 150mg after 5th shock
MAX DOSE: 450mg