Pharmacology [1] Adrenaline is a naturally occurring catecholamine which primarily acts on Alpha (? ) and Beta (? ) adrenergic receptors. The actions of these receptors cause an increase in heart rate (? 1), increase in the force of myocardial contraction (? 1), increase in the irritability oftheventricles(? 1), bronchodilation (? 2) and peripheral vasoconstriction(? 1). Precautions • Patients taking monoamine oxidase inhibitors (MAOIs) • Hypovolaemicshock • Hypertension Metabolism [2] The majority of circulating adrenaline is metabolised by sympatheticnerveendings.
Itissubjecttotheprocessof mitochondrial enzymatic breakdown by monoamine oxidase atthesynapticlevel. Side effects • • • • Anxiety Hypertension Palpitations/tachyarrhythmias Pupil dilation Indications • Anaphylaxis OR severe allergic reaction • Severe life-threatening bronchospasm OR silent chest (Patients must only be able tospeakinsinglewordsAND/ORhave haemodynamic compromise AND/OR an ALOC. ) • Bradycardia with poor perfusion (unresponsivetoatropineAND/ORTCP) • Cardiac arrest • Croup (with stridor at rest) • Shockunresponsivetoadequatefluid resuscitation (excluding haemorrhagic cause).
Presentation • Ampoule, 1 mg/1 mL (1:1,000) adrenaline • Ampoule, 1 mg/10 mL (1:10,000) adrenaline Onset 30 seconds (IV) 60 seconds (IM) Duration 5–10 minutes Half-life 2 minutes Schedule • 1 mg/1 mL (1 : 1,000), S3 (therapeutic poisons). • 1 mg/10 mL (1 :10,000), unscheduled. Special notes • 1 : 1,000 (1 mg/mL) adrenaline presentation should be used for all nebuliser administration. • 1:10,000 (1 mg/10 mL ) or a 1 : 100,000 (100 mcg/10 mL ) adrenaline preparation should be used for all low dose IV injections (e. g. paediatric cardiac arrest) – Ensure all syringes are appropriately labelled.
• Repeated IM injections to the same site may cause ischaemia and/or necrosis. • Suitablyqualifiedofficersshould,wherepossible, administer adrenaline infusions through an appropriately placed CVL. • Suitablyqualifiedofficersshould,wherepossible, utiliseinvasivepressuremonitoringforpatientsbeing administed adrenaline infusions. • Adrenaline infusions must be administered through a dedicated line. • AllcannulaeandIVlinesmustbeflushedthoroughly with sodium chloride 0. 9% following each medication administration. Routes of administration.
Nebuliser (NEB) Intramuscular injection (IM) Intraosseous injection (IO) Intravenousinfusion(IVINF) (QCC and QAS road taskings) Adrenaline – Page 2 of 4 Drug therapy protocols Version 1. 0 – September 2011 Adrenaline Page 3 of 4 Adult dosages Anaphylaxis OR severe allergic reaction IM 300 mcg NEB 5 mg Single dose only. Repeated at 5 minuteintervals. No maximum dose. Adult dosages (continued) Cardiac arrest IV IO 1 mg Repeated at 3 – 5 minuteintervals. No maximum dose. 1 mg Repeated at 3 – 5 minuteintervals. No maximum dose. May be administered for minor facial or tongue swelling thought to be allergic in origin.
If stridor present, IM or IV adrenaline must be administered. Shock unresponsivetoadequatefluidresuscitation (excluding haemorrhagic cause) IV IO 20 – 50 mcg Repeated at 1 minuteintervals. No maximum dose. 20 – 50 mcg Repeated at 1 minuteintervals. No maximum dose. IV IO 20 – 50 mcg Repeated at 1 minuteintervals. No maximum dose. 20 – 50 mcg Repeated at 1 minuteintervals. No maximum dose. Commence infusion at 2 mcg/minute (2 mL/hour) and increase by 1 – 2 mcg/minute (1–2 mL/hour) every3 – 5 minutes as determined by MAP. Severe life-threatening bronchospasm OR silent chest (patients must only be able to speak in single words AND/OR have haemodynamic compromise AND/OR an ALOC).
IM IV IO 300 mcg Repeated at 5 minuteintervals. No maximum dose. 20 – 50 mcg Repeated at 1 minuteintervals. No maximum dose. 20 – 50 mcg Repeated at 1 minuteintervals. No maximum dose. IV INF Syringe preparation: Mix 3 mg of 1 : 1,000 adrenaline (3 mL) with 47 mL of sodium chloride 0. 9% in a 50mLsyringetoachieveafinalconcentrationof 60 mcg/mL. Ensure all syringes are appropriately labelled. Bradycardia with poor perfusion (unresponsive to atropine AND/OR TCP).
IV IO 20 – 50 mcg Repeated at 1 minuteintervals. No maximum dose. 20 – 50 mcg Repeated at 1 minuteintervals. No maximum dose. Paediatric dosages Anaphylaxis OR severe allergic reaction IM > 6 years – 300 mcg Repeated at 5 minuteintervals. No maximum dose. < 6 years – 150 mcg Repeated at 5 minuteintervals. No maximum dose. Paediatric dosages Cardiac arrest IV > 10 kg ( > 1 year ) – 10 mcg/kg Repeated at 3 – 5 minuteintervals. No maximum dose. < 10 kg (< 1 year ) – 100 mcg Repeated at 3 – 5 minuteintervals. No maximum dose. NEB 5 mg Single dose only.
May be administered for minor facial or tongue swelling thought to be allergic in origin. If stridor present, IM or IV adrenaline must be administered. 2 mcg/kg Single dose not to exceed 50 mcg. Repeated at 2 minuteintervals. No maximum dose. 2 mcg/kg Single dose not to exceed 50 mcg. Repeated at 2 minuteintervals. No maximum dose. Croup (with stridor at rest) NEB 5 mg Single dose only. IV IO (excluding haemorrhagic cause) Shock unresponsivetoadequatefluidresuscitation IV 2 mcg/kg Single dose not to exceed 50 mcg. Repeated at 2 minuteintervals. No maximum dose.
2 mcg/kg Single dose not to exceed 50 mcg. Repeated at 2 minuteintervals. No maximum dose. Severe life-threatening bronchospasm OR silent chest (patients must only be able to speak in single words AND/OR have haemodynamic compromise AND/OR an ALOC) IO IM > 6 years – 300 mcg Repeated at 5 minuteintervals. No maximum dose. < 6 years – 150 mcg Repeated at 5 minuteintervals. No maximum dose. 2 mcg/kg Single dose not to exceed 50 mcg. Repeated at 2 minuteintervals. No maximum dose. 2 mcg/kg Single dose not to exceed 50 mcg. Repeated at 2 minuteintervals. No maximum dose.
Bradycardia with poor perfusion (unresponsive to atropine AND/OR TCP) IV ConsultationwithQASon-callmedicalofficer required. IV IO Adrenaline – Page 4 of 4 Drug therapy protocols Version 1. 0 – September 2011 Amiodarone Page 1 of 4 Drug class Anti-arrhythmic Contraindications • Cardiac arrest ( refractory VF or pulseless VT ): – Nil • Critical care patients requiring anti-arrhythmic therapy: – KSAR – bradycardia – severe conduction disorders (unless pacemaker or AICD in situ) – concomitant use of anti-arrhythmics that prolong the QT interval [3] – pregnancy and/or lactation Pharmacology [1].
Amiodarone prolongs the duration of the action potential and therefore the refractory period of atrial, nodal and ventricular tissues. It also reduces conduction across all cardiac tissue – including myocardial and conducting system cells. Amiodarone demonstrates electrophysiological proprieties across all Vaughan-Williams Class groups, which enables a broad spectrum of activity. Metabolism The majority of amiodarone is excreted via the liver and GI tract by biliary excretion; there may be some hepatic recirculation. [1] Indications • Cardiac arrest (refractory VF or pulseless VT).
[2] Precautions • Cardiac arrest (refractory VF or pulseless VT): – concomitant use of anti-arrhythmics that prolong the QT interval – thyroid disease [4] •Critical care patients during interfacilty transport: – hypotension – thyroid disease • Critical care patients requiring anti-arrhythmic therapy Side effects • • • • Hypotension Bradycardia Nausea and/or vomiting Peripheral paraesthesia Presentation • Ampoule, 150 mg/3 mL amiodarone (Cordarone X ®) [5] Special notes • If patient is on oral amiodarone, the protocols below continue to be authorised.
• If lignocaine 2% has been administered to a patient with conscious VT that progresses into cardiac arrest, the protocols below continue to be authorised. [2] • If the patient is in Torsade de Pointes due to suspected prolonged QT interval from excess amiodarone administration, magnesium sulphate administration is to be considered. [6] •Aftercompletionofarisk/benifitanalysis,theQAS authorises the administration of sodium chloride 0. 9% (flushorrunningIVline)followingamiodaroneincardiac arrest, despite manufacturer’s recommendations. [7] Onset (IV) 5 minutes Duration (IV) 30 minutes Half-life (elimination).
14–110 days (with chronic dosing) Schedule • S4 (Restricted drugs). Routes of administration Intravenous injection (IV) Intraosseous injection (IO) Intravenous infusion (IV INF ) (QCC taskings only) Amiodarone – Page 2 of 4 Drug therapy protocols Version 1. 0 – September 2011 Amiodarone Page 3 of 4 Adult dosages Cardiac arrest (refractory VF or pulseless VT) IV 300 mg Slow push over 2 minutes. Repeated once at 150 mg after 5 minutes. Total maximum dose – 450 mg. Adult dosages (continued) Critical care patients requiring anti-arrhythmic therapy IV INF QCC consultation and approval required in all situations.
Continue amiodarone infusions already commenced at hospital, using the same concentration and administration rate already established. This may involve withdrawing previously mixed and labelled solutions from the referring hospital. Should the QCC medical coordinator request an amiodarone infusion be commenced, the following procedure is to be undertaken. Loading dose – 300 mg over 30 minutes Syringe preparation: Mix 300 mg (6 mL) of amiodarone with 44 mL of glucose 5% in a 50mLsyringetoachieveafinalconcentrationof 6 mg/mL. Ensure all syringes are appropriately labelled.
Administer via syringe driver at a rate of 100 mL/hour (over 30 minutes). Maintenance dose – 900 mg over 24 hours Syringe preparation: Mix 150 mg (3 mL) of amiodarone with 47 mL of glucose 5% in a 50 mL syringetoachieveafinalconcentrationof3mg/ mL. Ensure all syringes are appropriately labelled. Administer via syringe driver at the rate of 12. 5 mL/ hour. Maintenance infusion is to be commenced immediately following the loading dose and is to continue for a period of 24 hours with a total of 900 mg amiodarone administered. IO 300 mg Slow push over 2 minutes. Repeated once at 150 mg after 5 minutes..
Total maximum dose – 450 mg. Paediatric dosages Cardiac arrest (refractory VF or pulseless VT) IV 5 mg/kg Slow push over 2 minutes. Single dose only. Syringe preparation: Mix 150 mg (3 mL) of amiodarone with 12 mL of glucose 10% (totalling 15 mL) in a 20 mL syringe to achieve afinalconcentrationof10mg/mL. 5 mg/kg Slow push over 2 minutes. Single dose only. Syringe preparation: Mix 150 mg (3 mL) of amiodarone with 12 mL of glucose 10% (totalling 15 mL) in a 20 mL syringe to achieve afinalconcentrationof10mg/mL. IO Amiodarone – Page 4 of 4 Drug therapy protocols Version 1. 0 – September 2011 Aspirin Page 1 of 2.
Drug class Antiplatelet Indications [1] Pharmacology • Suspected ACS [2] • Acute cardiogenic pulmonary oedema Aspirin inhibits platelet aggregation by irreversibly inhibiting cyclo-oxygenase, reducing the synthesis of thromboxane A2 (an inducer of platelet aggregation) for the life of the platelet. This action forms the basis of preventing platelets from aggregating to exposed collagen fibres at the site of vascular injury. Contraindications • KSAR to aspirin or other NSAIDs • Chest pain associated with psychostimulant overdose [3] • Bleeding disorders • Current GI bleeding or peptic ulcers • Patients < 18 years.
Metabolism [1] Aspirin is converted to salicyclic acid in many tissues, but primarily in the GI mucosa and liver. It is subsequently excreted by the kidneys. Precautions • Possible aortic aneurysm or any other condition that may require surgery [4] • Pregnancy • History of GI bleeding or peptic ulcers • Concomitant anticoagulant therapy (excluding clopidogrel ) Side effects • • • • • Epigastric pain/discomfort Nausea and/or vomiting Gastritis GI bleeding [5] NSAID induced bronchospasm [6] Presentation • Tablet (white), 300 mg aspirin Special notes.
• In suspected ACS or acute cardiogenic pulmonary oedema aspirin should be administered following the initial dose of glyceryl trinitrate (if indicated). Onset ? 10 minutes (variable) Duration ? 1 week (antiplatelet) Half-life 3. 2 hours (300–650 mg) • Aspirin administration is indicated for patients with suspected ACS or acute cardiogenic pulmonary oedema, even if pain free. • Patients who have had < 300 mg aspirin in the previous 24 hours and who present with suspected ACS or acute pulmonary oedema should be administered a dose of aspirin that equates to a total daily dose of 300 – 450 mg. Schedule • S2 (Therapeutic poisons).
Routes of administration Per oral (PO) Adult dosages • Suspected ACS • Acute cardiogenic pulmonary oedema PO ? 18 years – 300 mg Chewed and followed by a small sip of water (where possible). Note: QAS officers are not authorised to administer aspirin to patients under 18 years of age. Aspirin – Page 2 of 2 Drug therapy protocols Version1. 0–September2011 Atropine Page 1 of 4 Drug class Antichlolinergic(antimuscarinic) Contraindications • KSAR Pharmacology [1] Atropineworksbyinhibitingtheactionoftheparasympathetic nervoussystemallowingforanunchallengedsympathetic response. Itsuccessfullyblockstheactionofthevagusnerve.
ontheheart,increasestherateoftheSAnode,conduction throughtheAVnodeandblocksexocrineglandactivity. Precautions • • • • Atrialflutter Atrialfibrillation AMI Glaucoma Metabolism Atropineismetabolisedbytheliverandexcretedmainlyby thekidneys. [1] Indications • Bradycardia(withpoorperfusion) • Envenomation(withincreasedparasympathetic activity) •Hypersalivation(withketamineadministration) • Organophosphate toxicity(withcardiacAND/OR respiratorycompromise) Side effects • • • • Agitation Hallucinations Dilatedpupils Drymouth/dryskin/reducedbronchialand gastricsecretions • Tachycardia Presentation • Ampoule,1. 2mg/1mLatropine.
Special notes • Adoseofupto1. 2mgofatropineisgenerallysufficientto resolvebradycardiainadultpatients. Subsequentdoses inpatientswhofailtorespondisnotusuallybeneficial. [2] • Smalldosesofatropinemaycauseparadoxical bradycardia. [3] • Atropinerequirementsfororganophosphatetoxicityvary enormouslybetweenpatientsandorganophosphates. [4] • Targetatropinisationfororganophosphatetoxicityis achievedwhenthepatienthasthefollowingendpoints: – chestclearandnowheezeonauscultation – heartrate>80beatsperminute – systolicBP>80mmHg • Organophosphatetoxicityinducedtachycardiashouldnot prohibitatropineadministrationifrespiratorydistressis.
present(e. g. profuseoraland/orbronchialsecretions). • Totalloadingdose(ESoR–aeromedicalIVINFprotocol) isdefinedasthesumoftheinitialdosesgivenatthe beginningofacourseoftreatmentpriortoadministering alowermaintenancedose. • AllcannulaeandIVlinesmustbeflushedthoroughly withsodiumchloride0. 9%followingeachmedication administration. Onset (IV) 1–2minutes ( eak15–50minutes p ) Duration (IV) Upto5hours Half-life (elimination) 3–4hours Schedule • S4(Restricteddrugs). Routes of administration Intramuscularinjection(IM) Intravenousinjection(IV) Intraosseousinjection(IO) Intravenousinfusion(IVINF) (QCCtaskingsonly)
Atropine–Page2of4 Drug therapy protocols Version1. 0–September2011 Atropine Page 3 of 4 Adult dosages Bradycardia (with poor perfusion) IV IO 600 mcg Repeatedonceafter2 minutes. Total maximum dose 1. 2 mg. 600 mcg Repeatedonceafter2 minutes. Total maximum dose 1. 2 mg. Adult dosages (continued) compromise) Organophosphate toxicity (with cardiac AND/OR respiratory IM ECPofficersrequireappropriatemedicalofficerconsultationandapprovalinallsituations. 1. 2 mg Repeated at 5 minuteintervals. No maximum dose. ECPofficersrequireappropriatemedicalofficer consultationandapprovalinallsituations. 1.
2 mg Repeated at 5 minutesintervals. No maximum dose. 1. 2 mg Repeatedevery5 minutesintervals. No maximum dose. Envenomation (with increased parasympathetic activity) IM ECPofficersrequireappropriatemedicalofficer consultationandapprovalinallsituations. 1. 2 mg Repeated at 5 minute intervals. No maximum dose. ECPofficersrequireappropriatemedicalofficer consultationandapprovalinallsituations. 1. 2 mg Repeated at 5 minuteintervals. No maximum dose. 1. 2 mg Repeated at 5 minuteintervals. No maximum dose. IV IO IV INF IV IO Hypersalivation (with ketamine administration) IV 600 mcg Single dose only.
QCCconsultationandapprovalrequired inallsituations. 5 – 10 mL/hour(10–20%ofloadingdose/ hour)tomaintainatropinisation. Syringepreparation:Mixthetotalloading doseofatropinewithsodiumchloride0. 9% tomakeupatotalvolumeof50mL. Ensure allsyringesareappropriatelylabelled. Paediatric dosages Bradycardia (with poor perfusion) IV 20 mcg/kg Singledosenottoexceed600mcg. Repeatedonceafter2 minutes. Total maximum dose 40 mcg/kg. 20 mcg/kg Singledosenottoexceed600mcg. Repeatedonceafter2 minutes. Total maximum dose 40 mcg/kg. Paediatric dosages (continued) Hypersalivation (with ketamine administration) IV.
20 mcg/kg Single dose only, not to exceed 600 mcg. IO • Envenomation (with increased parasympathetic activity) • Organophosphate toxicity (with cardiac AND/OR respiratory compromise) IM ECPofficersrequireappropriatemedicalofficer consultationandapprovalinallsituations. 20 mcg/kg Singledosenottoexceed600mcg. Repeated at 5 minuteintervals. No maximum dose. ECPofficersrequireappropriatemedicalofficer consultationandapprovalinallsituations. 20 mcg/kg Singledosenottoexceed600mcg. Repeated at 5 minuteintervals. No maximum dose. 20 mcg/kg Singledosenottoexceed600mcg.
Repeated at 5 minute intervals. No maximum dose. IV IO Atropine–Page4of4 Drug therapy protocols Version 1. 0 – September 2011 Benztropine Page 1 of 2 Drug class Anticholinergic Side effects • • • • • Dilated pupils Dry mouth Nausea and/or vomiting Tachycardia Toxic psychosis including confusion and visual hallucinations • Urinary retention and/or dysuria Pharmacology [1] Benztropine is synthesised from components of the atropine and diphenhydramine drug molecules. It possesses strong anticholinergic and antihistamine properties whilst also inhibiting dopamine re-uptake.
These properties enable the drug to restore some balance between acetylcholine and dopamine in the central nervous system, thereby alleviating acute dystonias. Metabolism Hepatic. [1] Presentation Indications • Acute dystonic reaction • Ampoule, 2 mg/2 mL benztropine (Cogentin®) [2] Onset (IV) Contraindications • KSAR • Tardive Dyskinesia • Children < 3 years 1 – 2 minutes Duration (IV) 1 – 2 hours Half-life (elimination) ? 16 hours Schedule • S4 (Restricted drugs). Precautions • Sedative effects of other drugs may be enhanced • Children < 12 years Routes of administration.
Intramuscular injection (IM) Intravenous injection (IV) Adult dosages Acute dystonic reaction IM IV 1 – 2 mg Single dose only. 1 – 2 mg Single dose only. Special notes • Because of its atropine-like side effects, benztropine is contraindicated in children < 3 years and should be used with caution in older children. [1] • Thereisnosignificantdifferenceintheonsetofeffect following IV or IM injection. [3] Paediatric dosages Acute dystonic reaction IM IV ? 3 years – 20 mcg/kg Single dose only. ? 3 years – 20 mcg/kg Single dose only. Note:QASofficersarenotauthorisedtoadministerbenztropine to paediatric patients < 3 years.
Benztropine – Page 2 of 2 Drug therapy protocols Version1. 0–September2011 Boxjellyfishantivenom Page 1 of 4 Drug class Antivenom Precautions • The antivenom is a foreign protein, which can cause sensitisation, allergic reaction or anaphylaxis [2] Pharmacology BoxJellyfishantivenomcontainsconcentratedimmunoglobulin thatactstoneutralisethetoxinspresentinthevenomofthebox jellyfish(Chironexfleckeri). [1] Side effects • Allergic reaction including anaphylaxis and delayed serum sickness [2] • Intense stinging sensation on injection Metabolism In muscle tissue and the liver.
[1] Indications • Boxjellyfish(Chironexfleckeri envenomation ) associated with any of the following: – a patient currently in cardiac arrest – decreased level of consciousness – cardiac AND/OR respiratory distress or collapse – total surface area affected greater than half thesurfaceareaofonelimb – intractablepainunrelievedbyicepacks, methoxyfluraneAND/ORnarcoticanalgesia. Presentation • Ampoule, 20,000 units/1. 5 – 4 mL boxjellyfishantivenom Onset(IV) Notavailable Duration(IV) Notavailable Half-life(elimination) Notavailable Schedule • S4 (Restricted drugs).
Contraindications • KSAR Routes of administration Intramuscular injection (IM) Intravenous injection (IV) Special notes • Ifapatientisincardiacarrestduetoboxjellyfish envenomation,boxjellyfishantivenomisonlytobe administered following the commencement of effective CPR, advanced life support measures and administration of cardioactive drugs. [2] • Atalltimesduringantivenomtherapyadrenalinemustbe availableincaseofananaphylacticreaction. Ifreaction occurs,immediatelyceasetheadministrationofbox jellyfishantivenomandtreatpatientinaccordancewith the QAS Anaphylaxis and allergy CPG.
• The dose of antivenom is related to the dose of venom, notbasedonthesizeofthepatient. [1] • IV injection is the preferred route of administration for all indications. • 60,000 units of antivenom may equate to a volume of upto12mL. ForthepurposeofIMadministration,officers may administer up to 2 mL in each Deltoid muscle and up to 5 mL in each Vastus Lateralis muscle. • Boxjellyfishantivenommustbeprotectedfromlight andstoredbetween2–8°C. DONOTFREEZE. [2] Boxjellyfishantivenom–Page2of4 Drug therapy protocols Version1. 0–September2011 Boxjellyfishantivenom Page 3 of 4 Adult dosages.
Boxjellyfish(Chrionexfleckeri) envenomation associated with any of the following: • • • • Decreased level of consciousness Cardiac AND/OR respiratory distress or collapse Total surface area affected greater than half the surface area of one limb Intractablepainunrelievedbyicepacks,methoxyfluraneAND/OR narcotic analgesia IM IV 60,000units Single dose only. 20,000units Slow push over 10 minutes. Single dose only. Syringe preparation: Mix 20,000 units of antivenom with sodium chloride 0. 9% toachieveafinalconcentrationof20,000 units/20 mL. Boxjellyfish(Chrionexfleckeri) envenomation.
associated with a patient currently in cardiac arrest IV 20,000units Slow push over 2–5 minutes. Repeated immediately up to 2 times. Totalmaximumdose60,000units. Syringe preparation: Mix 20,000 units of antivenom with sodium chloride 0. 9% toachieveafinalconcentrationof20,000 units/20 mL. Paediatric dosages BoxJellyfish(Chrionexfleckeri)envenomation associated with any of the following: • • • • Decreased level of consciousness Cardiac AND/OR respiratory distress or collapse Total surface area affected greater than half the surface area of one limb Intractablepainunrelievedbyicepacks,methoxyfluraneAND/OR narcotic analgesia.
IM IV 60,000units Single dose only. 20,000units Slow push over 10 minutes. Single dose only. Syringe preparation: Mix 20,000 units of antivenom with sodium chloride 0. 9% toachieveafinalconcentrationof20,000 units/20 mL. BoxJellyfish(Chrionexfleckeri) envenomation associated with a patient currently in cardiac arrest IV 20,000units Slow push over 2–5 minutes. Repeated immediately up to 2 times. Totalmaximumdose60,000units. Syringe preparation: Mix 20,000 units of antivenom with sodium chloride 0. 9% toachieveafinalconcentrationof20,000 units/20 mL. Boxjellyfishantivenom–Page4of4
Drug therapy protocols Version 1. 0 – September 2011 Calcium gluconate 10% Page 1 of 2 Drug class Electrolyte Precautions • Respiratory acidosis Pharmacology [1] Calcium plays an integral role in the muscular and neural systems. It is involved in skeletal muscle contraction, excitation coupling in cardiac and smooth muscle and acts as an intracellular 2nd messenger. These effects combine to exert a positive inotropic effect in the post cardiac arrest patient. It additionally has a role in cardiac membrane stabilisation in hyperkalaemia. Side effects.
• Suspected hyperkalaemic cardiac arrest: – nil • For all other QAS indications IV administration may cause: – syncope – hypotension – bradycardia – cardiac dysrrhythmias – cardiac arrest Metabolism Mostofthecalciumfilteredbytherenalglomeruliisreabsorbed; the remainder is excreted in faeces. [2] Indications • Suspected hyperkalaemic cardiac arrest • Severe hyperkalaemia (with haemodynamic compromise AND/ORsignificantcardiacrhythm disturbance) • Calcium channel blocker toxicity • Hypotension associated with a magnesium infusion (that fails to respond to intravenous fluidtherapy) Presentation.
• Ampoule, 0. 953 g/10 mL calcium gluconate 10% Onset (IV) Contraindications • KSAR • Digoxin (digitalis) overdose 1–3 minutes Duration (IV) 30–60 minutes (in hyperkalaemia) Half-life (elimination) Not applicable Schedule • Unscheduled. Adult dosages • Suspected hyperkalaemic cardiac arrest • Severe hyperkalaemia (with haemodynamic compromise AND/OR significantcardiacrhythmdisturbance) Routes of administration Intravenous injection (IV) Intraosseous injection (IO) • Calcium channel blocker toxicity • Hypotension associated with a magnesium infusion (thatfailstorespondtointravenousfluidtherapy).
IV Special notes • AllcannulaeandIVlinesmustbeflushedthoroughly with sodium chloride 0. 9% following each medication administration. 10 mL Slow push over 2 – 5 minutes. Repeated once at 10 minutes. 10 mL Slow push over 2 – 5 minutes. Repeated once at 10 minutes. IO Paediatric dosages • Suspected hyperkalaemic cardiac arrest • Severe hyperkalaemia (with haemodynamic compromise significantcardiacrhythmdisturbance) AND/OR • Calcium channel blocker toxicity • Hypotension associated with a magnesium infusion (thatfailstorespondtointravenousfluidtherapy) IV IO 0.
2 mL/kg Slow push over 2 – 5 minutes. Repeated once at 10 minutes. 0. 2 mL/kg Slow push over 2 – 5 minutes. Repeated once at 10 minutes. Calcium gluconate 10% – Page 2 of 2 Drug therapy protocols Version 1. 0 – September 2011 Ceftriaxone Page 1 of 2 Drug class Antibiotic Side effects • Nausea and/or vomiting • Pain at the IM administration site Pharmacology Ceftriaxone is third generation cephalosporin antibiotic with a bactericidal action. [1] Metabolism Ceftriaxone is excreted as a variety of active and inactive metabolites from the body through urine, bile and faeces.
[1] Presentation • Vial (powder), 1 g ceftriaxone (Rocephin®) [3] Indications • Suspected meningococcal septicaemia (with a non-blanching petechial AND/OR purpuric rash) Onset 30 seconds (IV) 60 seconds (IM) Duration 5–10 minutes Half-life 2 minutes Contraindications • KSAR to cephalosporin drugs • Known anaphylaxis or severe allergic reaction to penicillin based drugs – (isolated minor drug rash attributed to penicillin does not contraindicate the use of ceftriaxone) [2] Schedule • S4 (Restricted drugs). Routes of administration.
Intramuscular injection (IM) Intravenous injection (IV) Intraosseous injection (IO) [4] Precautions • Nil Special notes • AllcannulaeandIVlinesmustbeflushedthoroughly with sodium chloride 0. 9% following each medication administration. Paediatric dosages petechial AND/OR purpuric rash) Suspected meningococcal septicaemia (with a non-blanching IM Adult dosages petechial AND/OR purpuric rash) 50 mg/kg (rounded up to the nearest 5 kg) Syringe preparation: Reconstitute 1 g of ceftriaxone with 3. 6 mL of water for injection toachieveafinalconcentrationof1g/4mL (250 mg/mL).
Weight < 5 kg 5 – 10 kg 10 – 15 kg > 15 kg Dose 250 mg 500 mg 750 mg 1g Volume 1 mL 2 mL 3 mL 4 mL Suspected meningococcal septicaemia (with a non-blanching IM 1g Syringe preparation: Reconstitute 1 gm with 3. 6mLofwaterforinjectiontoachieveafinalconcentration of 1 g/4 mL (250 mg/mL). 1g Slow push over 3 – 5 minutes. Syringe preparation: Reconstitute 1 gm with 9. 6mLofwaterforinjectiontoachieveafinal concentration of 1 g/10 mL (100 mg/mL). IV IV 50 mg/kg (rounded up to the nearest 5 kg) Slow push over 3 – 5 minutes. Syringe preparation: Reconstitute 1 g of ceftriaxone with 9.
6 mL of water for injection ina10mLsyringetoachieveafinal concentration of 1 g/10 mL (100 mg/mL). Weight < 5 kg 5 – 10 kg 10 – 15 kg > 15 kg Dose 250 mg 500 mg 750 mg 1g Volume 2. 5 mL 5 mL 7. 5 mL 10 mL Ceftriaxone – Page 2 of 2 Drug therapy protocols Version1. 0–September2011 Clopidogrel Page 1 of 2 Drug class Antiplatelet Contraindications • Identical to the contraindication list for prehospitalfibrinolysisandanticoagulation, unlessspecificallyauthorisedundertherelevant LWI. (RefertoQAScoronaryarteryreperfusionchecklist and LWI. ) • KSAR • Patientscurrentlytakingclopidogrel • Patients <18years.
Pharmacology [1] Clopidogrelisaspecificandpotentplateletaggregationinhibitor. Itselectivelyinhibitsthebindingofadenosinediphosphate(ADP) toitsplateletreceptor,therebyinhibitingplateletaggregation. Metabolism Hepaticmetabolismwithnearequalamountsexcretedinurine and faeces. [1] Indications • ForpatientswithSTEMI (asdefinedintheQAS coronaryarteryreperfusionchecklist)AND: – whohavebeenaccepted for pPCI (asanadjunctmedicationtoaspirinand heparin) [2] OR – whohavereceived fibrinolytic therapy (asanadjunctmedicationtoaspirin, enoxaparinandtenecteplase)[3] Precautions • Severerenalimpairment.
Side effects • • • • • Haemorrhage Stomachupsetand/orpain Diarrhoea Constipation Headacheand/ordizziness Presentation • Tablet(pink),75mg,clopidogrel(Iscover®) [4] Special notes • Clopidogrelisnottobegiveninisolation. Ifheparin orenoxapariniscontraindicatedthenclopidogrelis also contraindicated. • Ifthepatientisontheirownclopidogrel(e. g. Plavix® orIscover®)medication,thereisnorequirementfor a loading dose. Onset (PO) ?30min (within5hoursofa 300mgloadingdose 80%ofplatletactivity willbeinhibited) Duration (PO) 7–10days (antiplatelet) Half-life (PO) Paediatric dosages 8hours Adult dosages.
Patients with STEMI (as defined by the QAS coronary artery reperfusion checklist) who have been accepted for pPCI (and have been administered aspirin and heparin) Schedule • S4(Restricteddrugs). Special notes PO ?18years–600 mg Swallowedwithasmallquantityofwater. Routes of administration Per oral (PO) Patients with STEMI (as defined by the QAS coronary artery reperfusion checklist) who have received fibrinolytic therapy (and have been administered aspirin, enoxaparin and tenecteplase) PO ? 18years–300 mg Swallowedwithasmallquantityofwater. Clopidogrel – Page 2 of 2 Drug therapy protocols Version1. 0–September2011.
Enoxaparin Page 1 of 2 Drug class Anticoagulant Precautions • • • • • • Renal/hepatic impairment History of GI ulceration Diabetic retinopathy Low bodyweight (women < 45 kg and men < 57 kg) [1] Elderly Pregnancy and/or lactation Pharmacology [1] Enoxaparin has several actions on the coagulation pathway through its binding to antithrombin III. The antithrombotic activity is related to inhibition of thrombin generation and inhibition of two key cogagulation factors: factor Xa and thrombin. Metabolism Metabolism at the liver but mostly eliminated unchanged. [1] Side effects • Thrombocytopenia • Haemorrhage.
Indications • Patients with STEMI(asdefinedintheQAS coronary artery reperfusion checklist) AND who will receive QAS fibrinolytic therapy (as an adjunct medication to aspirin, clopidogrel and tenecteplase) [2] Presentation [3] • Ampoule, 40 mg/0. 4 mL enoxaparin sodium (Clexane®) Contraindications • KSARtoenoxaparinorheparin • Identical to contraindication list for prehospital fibrinolysis,unlessspecificallyauthorisedunder therelevantLWI. (SeetenecteplaseDTPand QAScoronaryarteryreperfusionchecklist. ) • Injection(prefilledsyringewithgraduatedmarkings), 100 mg/1 mL enoxaparin sodium (Clexane®) Onset (IV)
Immediate (peak 3 hours) Duration (IV) 12–24 hours Half-life (elimination) 4. 4 hours for 40 mg dose Schedule • S4(Restricteddrugs). Adult dosages Patients with STEMI (as defined in the QAS coronary artery reperfusion checklist) who will receive QAS fibrinolytic therapy (as an adjunct medication to aspirin, clopidogrel and tenecteplase) IV Loading dose – 30 mg Syringepreparation:Mix40mg(0. 4mL)of enoxaparin with 3. 6 mL of sodium chloride 0. 9% (totaling 4 mL) in a 5 mL syringe to achieveafinalconcentrationof10mg/mL. Discard 1 mL of the prepared solution to achieveafinalpreparationof30mg/3mL.
Subcutaneousinjectionmaintenance dose (listed below) is to be administered 15 minutes following IV enoxaparin loading dose. Maintenance dose – 1 mg/kg Single dose only, not to exceed 100 mg. To be administered 15 minutes following IV enoxaparin loading dose (listed above). Routes of administration Subcutaneousinjection(SUBCUT) Intravenous injection (IV) Special notes • For all IV administrations an enoxaparin 40 mg/0. 4 mL ampoule is to be used. • For all subcut administrations an enoxaparin 100 mg/1 mL graduatedprefilledsyringeistobeused.