precautions Flashcards
Adrenaline pre-cautions
Ischaemic Heart Disease
Hypertension
Hypovolaemia
Do not walk patient pre or post IM adrenaline administration in anaphylaxis - usually a minimum of 1 hour after 1 dose of Adrenaline and 4 hours if more than 1 dose of Adrenaline given
If given IV into a peripheral vein, follow each dose with a sodium chloride flush
Amiodarone pre-cautions
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)
Aspirin Precautions
Actively bleeding peptic ulcers.
Suspected AAA.
Aspirin / salicylate-sensitive asthmatics
Cophenylcaine precautions
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.
Pause between subsequent doses
Droperidol Precautions
Address organic causes for behavioural presentations at all times- eg. CVA, TBI, Hypoxia, Hypoglycaemia, etc
Post-ROSC agitation - consult ASMA / SOC CSP
Dementia patients – apply caution. Use lower doses
‘Agitated or Excited Delirium’, ‘Acute Behavioural Disturbance’ and ‘Drug Induced Psychosis’ are some alternative terms that may be used by other agencies
Sedation Warnings
Sedation is HIGH RISK – must only be carried out after careful deliberation between officers and must not be based primarily at the request or influence of other agencies on scene (e.g. Police etc.)
Positive RASS score does not automatically infer a need to sedate
Age <16 years old – sedation should prompt a prior ASMA consult wherever practicable
ETOH / Intoxication – apply caution
Repeat & Maintenance doses – have a low threshold to consult with ASMA where repeat or maintenance doses are required
Monitoring – SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops (~RASS -2 or below)
Positioning – DO NOT transport in supine position (increases risk of laryngospasm from secretions) – transport in lateral position
Airway & Breathing – monitor airway and breathing effort, including chest movement closely for signs of impairment. Prepare to support if required
Restraint – Prone and/or handcuffed to rear carries excessive risk and MUST NOT occur. Physical restraint in any position that amplifies the risk of positional asphyxia, must be closely observed for signs of air hunger and hypoxia
RASS scores must be agreed and documented
Weight – Estimated weight must be agreed before administration of any weight based medicines. This must be documented
The final decision to sedate lies with the most senior clinician on scene
Fentanyl pre-cautions
Elderly patients
Respiratory depression: especially those at risk e.g. patients with severe COPD
Patients currently on MAO inhibitors or MAO inhibitor use within previous 14 days
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: 100 microg
Adult < 70 years old: 200 microg
Adult > 70 (or frail): 100 microg
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.
Glucagon Precautions
Glucagon is effective in treating hypoglycaemia only if sufficient liver glycogen is present (i.e. it does not work on alcohol or anorexia induced hypoglycaemia).
Give complex carbohydrates orally when patient has responded to prevent recurrent hypoglycaemia
Even if fully recovered, patients should be encouraged to be transported to a medical facility to ensure effective follow up and review.
Glucose Oral Gel Precautions
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.
GTN precautions
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
Prime the bottle before using it for the first time by pressing the nozzle 5 times, spraying it into the air
Do not shake GTN bottle prior to administration
Assess BP before every dose
Severe hypotension is an uncommon side effect
Intoxication (effect are enhanced)
Phosphodiesterase 5 inhibitor medication administration in previous 4 days
Heparin precautions
Haemorrhagic risks in case of possible trauma.
Saline precautions
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)
Fluid Therapy for shock, DKA & Hyperosmolar Hyperglycaemic State: Initial fluid therapy is directed toward expansion of the intravascular, interstitial, and intercellular volume, all of which are reduced in hyperglycaemic crises and restoration of renal perfusion.
Ipratropium Bromide precautions
Glaucoma
Avoid contact with eyes.
Ketamine
Caution in patients with stable psychiatric disorders such as Schizophrenia
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
Analgesia for Non traumatic pain (IM / IV / IO) in opioid-dependent patients – consider SOC CSP consult
Methoxyflurane precautions
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
Midazolam precautions
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 consistent with the Sedative Warnings section below.
Psychostimulants, in toxic levels can produce severe agitation and psychotic behaviour
Paediatric patients:
Intramuscular administrations should always be prepared in a 1mL IM syringe
Have a low threshold to consult with ASMA when repeat or maintenance doses are required for sedation
Naloxone precautions
Polypharmacy overdose.
Half-life of naloxone is < 1 hour; repeat doses may be required to maintain effect with longer acting opioids and those with active metabolites (e.g. methadone, diphenoxylate, codeine). Observe patients who respond to naloxone for 2-3 hours after administration for signs of re-narcotisation.
Response to Naloxone is rapid; reconsider diagnosis if there is a failure to respond to 2 mg Naloxone.
Patients may be aggressive post Naloxone and administration due to hypoxia. Scene safety and personal safety are paramount.
IN naloxone is only for EMT scope only, unless no other routes available. For more information, see here.
Olanzapine precautions
Address organic causes for behavioural presentations at all times- eg. CVA, TBI, Hypoxia, Hypoglycaemia, etc
Dementia patients – apply caution. Use lower doses
Oral dispersible tablet may be dissolved in water (may slightly delay onset of action but still preferable in non-emergent cases)
‘Agitated or Excited Delirium’, ‘Acute Behavioural Disturbance’ and ‘Drug Induced Psychosis’ are some alternative terms that may be used by other agencies
Ondansetron precautions
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.
Salbutamol Sulphate
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.
TXA precautions
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.
Slow IV push is the first line management option. TXA can be given via an infusion, however, familiarity in using infusions and availability of an appropriate label to identify the infusion should dictate if this option is utilised.
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
