Precautions

Question 1

Adrenaline - 2

Answer 1

Ischaemic Heart Disease

Do not walk patient pre/post IM adrenaline administration in anaphylaxis

Question 2

Amiodarone - 4

Answer 2

Heart failure
Thyroid dysfunction
Amiodarone is only indicated for shock resistant or recurrent VF / pulseless VT
MUST NOT be diluted into NaCl (e.g. if infusion doses are advised via ASMA / CSP)

Question 3

Aspirin - 3

Answer 3

Actively bleeding peptic ulcers.
Suspected AAA.
Aspirin / salicylate-sensitive asthmatics

Question 4

Atropine Sulphate - 6

Answer 4

Isolated Bradycardia or link to traumatic cause is not an indication for atropine. All reversible causes should be addressed prior to consideration of Atropine.

It is advisable that a 12 Lead ECG is conducted prior to medication administration to rule out Acute Myocardial Infarction (STEMI) and Third-degree atrioventricular (AV) block.

If in doubt transmit 12-lead ECG to CSP SOC to discuss, or seek ASMA advice.

Bradycardia in children is usually a result of hypoxia or vagal stimulation. Ensure all reversible causes addressed and consider commencing resuscitation as per CPG if unresponsive.

Atropine may affect patients with glaucoma.

The maximum dose of Atropine that has shown to produce the desired effect in healthy adults is up to 3mg for bradycardia. In organophosphate poisoning: atropinisation might require significant repeat dosages and is achieved when with an increased HR, dilated pupils and decreased secretion, do not delay transport as atropinisation might not be achievable in the pre-hospital setting.

Question 5

Cophenylcaine - 3

Answer 5

Used with caution in patients with cardiovascular, hepatic and/or renal disease.
For oral use, nozzle inserted within the anterior 1/3 of mouth to avoid gag stimulation.
Each spray delivers 100 microlitres of fluid. The dose of lignocaine in each squirt is 5 mg and the dose of phenylephrine in each squirt is 0.5mg

Question 6

Droperidol - 7

Answer 6

Sedation of any patient <16 years of age should prompt a prior ASMA consult wherever practicable.

IV access in children should not be routine – sound judgement should apply

IV doses require sound judgement

Dementia patients – apply caution. Use lower doses

Organic causes such as suspected sepsis, traumatic brain injury or spontaneous intra-cranial event must be considered unlikely

‘Agitated or Excited Delirium’, ‘Acute Behavioural Disturbance’ and ‘Drug Induced Psychosis’ are some alternative terms that may be used by other agencies

SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops (~RASS <0)

Question 7

Fentanyl - 8

Answer 7

Elderly patients

Respiratory depression: especially those at risk e.g. patients with severe COPD

Patients on MAO inhibitors

Caution in larger doses of women in active labour

Use of IV Ketamine as analgesic prior to minimum (age dependant) dose of IV Fentanyl requires ASMA authorisation:
Paediatric: 100mcg
Adult < 70 years old: 200mcg
Adult > 70 (or frail): 100mcg

Administer slowly

Cease administration prior to calculated dose if desired effect is obtained.

Patients under extended care (e.g. ‘ramped’ patients) who have already been administered pain relief should have careful consideration with regards to the dosages of fentanyl administered, titrating only to effect.

Question 8

Glucagon - 2

Answer 8

Glucagon is effective in treating hypoglycaemia only if sufficient liver glycogen is present (eg: it does not work on alcohol or anorexia induced hypoglycaemia).

Even if fully recovered, patients should be encouraged to be transported to a medical facility to ensure effective follow up and review.

Question 9

Glucose 10% (IV) - 9

Answer 9

Patients should ideally be cannulated with a large gauge cannula into a large vein, with patency confirmed with a free flowing bolus (>20ml) of 0.9% normal saline, before administering glucose 10% using a 20ml syringe via the injection port, titrated to effect. Administration via an IO should utilise a 20mL syringe and a three way tap.

High concentration of IV glucose may aggravate dehydration due to its hypertonicity whereby it draws water from the cells.

IV glucose is corrosive and IV patency must be ensured before administration.

Careful titration of glucose in head injured patients is vital as glucose leaking into CNS tissue will aggravate the injury, resulting in cerebral oedema.

Monitor blood glucose level carefully; beware of drop in level again after the patient has recovered.

Even if fully recovered, patients should be encouraged to be transported to a medical facility to ensure effective follow up and review.

IO administration is only as a last resort after all other avenues have been exhausted and the patient needs
lifesaving glucose.

Do not wait on scene for glucose to take effect.

Note that repeat doses of Glucose 10% (Intravenous) may need to be repeated to achieve normoglycaemia.

Question 10

Glucose Oral Gel - 4

Answer 10

Have patient’s airway patent and in lateral position if unconscious.
Always consider patient’s airway when administering gel.
Even if fully recovered, patients should be encouraged to be transported to a medical facility to ensure effective follow up and review.
Will liquefy over 30°C, however it is still useable.

Question 11

Glyceryl Trinitrate - 5

Answer 11

Nitrates are an early intervention and should not be delayed until on the stretcher or inside the ambulance.
Administer to the patient in a seated or semi-recumbent position.
Do not shake GTN bottle prior to administration.
Assess BP before every dose.
Severe hypotension is an uncommon side effect.

Question 12

Heparin Sodium - 1

Answer 12

Haemorrhagic risks in case of possible trauma.

Question 13

Hydrocortisone - 3

Answer 13

Hypertension
The specific method of preparing hydrocortisone for injection can be found here.
Rarely, patients in adrenal crisis may present with severe psychosis

Question 14

Intravenous Crystalloid Solution - 1

Answer 14

Adult patients with penetrating trauma, ectopic pregnancy or aortic aneurysm with hypotension and signs of impaired organ perfusion may benefit from permissive hypotension (systolic blood pressure of 70mmHg)

Question 15

Ipratropium Bromide - 2

Answer 15

Glaucoma

Avoid contact with eyes.

Question 16

Ketamine - 6

Answer 16

Used with caution in patients with stable psychiatric disorders such as Schizophrenia

Sedation of any patient <16 years of age – should prompt a prior ASMA consult wherever practicable

Have a low threshold to consult with ASMA where repeat or maintenance doses are required for sedation

SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops (~RASS <0)

Use with caution in patients with hyperthyroidism or receiving thyroid replacement due to increased risk of hypertension and tachycardia.

Analgesia - IV Fentanyl minimum dose (age dependant as per CPG) should be given prior to IV Ketamine administration

Question 17

Lignocaine 1% - 1

Answer 17

Adverse drug reactions are rare when lignocaine is used as a local anaesthetic and is administered correctly.

Question 18

Methoxyflurane - 7

Answer 18

Use PenthroxTM inhaler with charcoal filter attached

Where administration in transit is necessary, the rear extractor fan must be used and the rear facing seat should remain vacant

Instruct the patient to breathe in through their mouth and out through their mouth via the inhaler. For maximum effect cover the air dilutor hole.

Initial breath is strong and may cause the patient to cough, so advise to take gently

Watch for drowsiness

If oxygen is required deliver separately

Place in a sealed plastic bag when not in use

Question 19

Midazolam - 5

Answer 19

Early monitoring as soon as practicable is required when administering midazolam; including SpO2, respiratory rate, pulse and blood pressure

SpO2 and etCO2 monitoring must be applied whenever level of consciousness drops (~RASS <0)

Paediatrics - have a low threshold to consult with ASMA when repeat or maintenance doses are required for sedation

Use of Midazolam after Ketamine sedation requires ASMA consult

Psychostimulants, in toxic levels can produce severe agitation and psychotic behaviour.

Question 20

Naloxone - 4

Answer 20

Polypharmacy overdose.

Naloxone half-life may be less than that of a longer acting opioids (e.g. methadone, diphenoxylate, codeine).

Response to Naloxone is rapid, reconsider diagnosis if there is a failure to respond to 2mg Naloxone.

Patients may be aggressive post Naloxone and administration due to hypoxia. Scene safety and personal safety are paramount.

Question 21

Olanzapine - 7

Answer 21

Sedation of any patient < 16 years of age –should prompt a prior ASMA consult wherever practicable.

Organic causes such as suspected sepsis, traumatic brain injury or spontaneous intra-cranial event must be considered unlikely

‘Agitated or Excited Delirium’, ‘Acute Behavioural
Disturbance’ and ‘Drug Induced Psychosis’ are some alternative terms that may be used by other agencies

Effects may be amplified in patients with alcohol intoxication

Oral dispersible tablet may be dissolved in water (may slightly delay onset of action but still preferable in non-emergent cases)

Early monitoring as soon as practicable is required when administering Olanzapine; including SpO2, respiratory rate, pulse and blood pressure

SpO2 and etCO2 monitoring must be applied whenever level of consciousness drops (~RASS < 0)

Question 22

Ondansetron - 2

Answer 22

Oral wafer is the preferred method of administration for ALL patients unless actively vomiting.
Administer IV Ondansetron slowly over 2 minutes (neat or diluted) to prevent blurred vision and dizziness.

Question 23

Oxygen - 3

Answer 23

If the target saturations cannot be maintained with the nasal cannula or medium concentration mask then change to a non-rebreather oxygen mask.

Oxygen increases the toxicity in paraquat poisoning, target saturations of 88–92%.

Remember that some conditions can affect SpO2 readings e.g. carbon monoxide poisoning and cold digits

Question 24

Paracetamol - 4

Answer 24

There is no evidence that fever itself worsens the course of an illness. The primary goal should be to improve overall comfort [1]

SJA do not support the use of paracetamol in infants < 6 months.

20 ml Paracetamol suspension bottle is single patient use only.

Only used enteral syringe/dropper with suspension

Question 25

Prednisolone - 3

Answer 25

30ml Bottle is single patient use only

Children who are on immunosuppressant drugs are more susceptible to infections than healthy children, e.g.: Chicken pox and measles

Impaired immune responsiveness

Question 26

Salbutamol - 5

Answer 26

A spacer / MDI is the preferred route for salbutamol administration where the patient presents with influenza like illness.

The use of a Metered dose inhaler (MDI) and spacer is equally as effective as nebulisation, in all asthma situations, where the patient is still able to adequately inhale.

Use of a nebuliser is recommended where the patient loses this ability.

Ambulance Transport Officers (ATO) are only authorised to use salbutamol MDI in a known asthmatic patient with respiratory distress.

If hypoxic, nebulise salbutamol in preference to MDI, to address both hypoxia and bronchospasm. The nebulised route also makes it possible to administer Ipratropium Bromide simultaneously.

Question 27

Tranexamic Acid - 7

Answer 27

TXA administration in the traumatic patient in the metropolitan area should ordinarily prompt transport to a major trauma centre

Rapid administration may lead to hypotension and dizziness.

No medications or blood products (except 0.9% Sodium Chloride Solution) should be added or co-administered through the same giving set.

Give as early as possible post event. Survival benefit is reduced by 10% for every fifteen minute delay with no benefit seen after 3 hours

Address critical interventions (airway management, control of major haemorrhage etc.) before administration of tranexamic acid.

Tranexamic acid administration should not delay transfer, noting it may be administered en route.

Safety during pregnancy has not been demonstrated, but the balance of risk is such that it should be administered if the indications are met in life threatening circumstances