PARA SCOPE DRUGS

Cefazolin - Mechanism of Action

• First-generation cephalosporin antibiotic with activity against gram-negative and gram-positive bacteria. It inhibits production of the bacterial cell wall, causing bacteria to die

Cefazolin - Indications

• Sepsis, where the source of infection appears to be the soft tissues or joint, and:

  • The patient is aged greater than or equal to 12 years, and

  • Has one or more clinical features indicating antibiotics, and

  • Time to hospital is greater than 30 mins

• Compound fracture

• Large contaminated wound

• Following chest decompression

• Following amputation

• Cellulitis. In this setting a single dose may be administered if the patient is not being directly referred (or transported) to a medical facility

Cefazolin - Contraindications

• Known severe allergy to cephalosporins

Cefazolin - Cautions

• N/A

Cefazolin - Use in pregnancy or when breastfeeding

• Safe and should be administered if indicated

Cefazolin - Dosage

• 1 g IV for an adult

• See paediatric drug dose tables for a child

Cefazolin - Administration

• Add approximately 4 ml of 0.9% sodium chloride to a 1 g ampoule and shake until dissolved

• Draw up the ampoule contents and dilute to a total of 10 ml

• Administer IV over 1-2 minutes preferably into a running line

Cefazolin - Common Adverse Effects

• N/A

Cefazolin - Usual Onset of Effect

• 30-60 minutes

Cefazolin - Usual Duration of Effect

• 6-8 hours

Cefazolin - Usual Preparation

• Ampoule containing 1 g as a powder for reconstitution

Cefazolin - Pharmacokinetics

• Predominantly excreted in the urine

• Clearance is prolonged if the patient has significant kidney impairment, but this does not alter the initial (loading) dose

Cefazolin - Common Interactions

• N/A

Cefazolin - Additional Information

• Rapid administration can cause pain and phlebitis, which is why it should be preferably administered into a running line

Ceftriaxone - Mechanism of Action

• Cephalosporin antibiotic with broad activity against gram-negative and gram-positive bacteria. It inhibits production of the bacterial cell wall, causing bacteria to die

Ceftriaxone - Indications

• Suspected meningococcal septicaemia

• Sepsis, where Cefazolin is not indicated and:

  • The patient is aged greater than or equal to 12 years, and

  • One or more clinical features indicating antibiotics are present, and

  • Time to hospital is greater than 30 mins

Ceftriaxone - Contraindications

• Anaphylaxis to cephalosporins

Ceftriaxone - Cautions

• N/A

Ceftriaxone - Use in pregnancy or when breastfeeding

• Safe and should be administered if indicated

Ceftriaxone - Dosage

• 2 g IV for an adult

• 2 g IM for and adult if IV access cannot be immediately obtained (meningococcal septicaemia only)

• See paediatric drug dose tables for a child

Ceftriaxone - Administration

• IV administration:

  • Add approximately 4 ml of 0.9% sodium chloride to a 2 g ampoule and shake until dissolved

  • Draw up the ampoule and dilute to a total of 10 ml

  • Discard unrequired volume before administration for a child

  • Administer IV over 1-2 minutes preferably into a running line

• IM administration:

  • Add 4 ml of 0.9% sodium chloride to a 2 g ampoule and shake until dissolved

  • Draw up the ampoule using two syringes with approximately half in each. The total volume will be 5 ml

  • Discard unrequired volvume before administration for a child

  • Administer one syringe into each lateral thigh. If this site is not suitable, use each lateral upper arm

Ceftriaxone - Common Adverse Effects

• N/A

Ceftriaxone - Usual Onset of Effect

• 30-60 minutes

Ceftriaxone - Usual Duration of Effect

• 24 hours

Ceftriaxone - Usual Preparation

• Ampoule containing 2 g as a powder for reconstitution

Ceftriaxone - Pharmacokinetics

• 50% is excreted in urine and 50% in bile

• Neither renal impairment nor hepatic impairment alter the initial (loading) dose

Ceftriaxone - Common Interactions

• N/A

Ceftriaxone - Additional Information

• Some references describe dissolving the drug using 1% lignocaine for IM injection, to reduce the pain of injection. In the setting of suspected meningococcal septicaemia this reduction in pain is not significant and it should be dissolved using 0.9% sodium chloride

• As meningococcal bacteria die they release endotoxins. The body’s immune response to endotoxin can cause profound worsening of shock following antibiotics administration. Be prepared to treat this with 0.9% sodium chloride IV, and metaraminol or adrenaline IV. It is rare for significant amounts of endotoxins to be released from other bacteria

Fentanyl - Mechanism of Action

• An opiate analgesic. It is an opiate agonist (or stimulator) that binds to opiate receptors in the brain and spinal cord causing analgesic

Fentanyl - Indications

• Moderate to severe pain

• Cardiogenic pulmonary oedema with severe anxiety

• Rapid sequence intubation

• Sedation post intubation

• Control of pain, agitation, or shortness of breath during the last days of life

• Autonomic Dysreflexia, even if the patient cannot feel pain

Fentanyl - Contraindications

• Known severe allergy

Fentanyl - Cautions

• Altered level of consciousness. It may further reduce the LOC

• Aged less than one year. Children under the age of one year are at increased risk of respiratory depression following opiate administration

• Respiratory depression or at high risk of respiratory depression.

• Labour. Opiates cross the placenta and may cause drowsiness and/or respiratory depression in the baby, particularly when administered within an hour or two of birth.

• Concurrent administration of other opiates, ketamine or midazolam. This will increase and prolong the effects

• Aged greater than or equal to 75 years, particularly if frail

• Signs of shock. Will make shock worse

Fentanyl - Use in pregnancy or when breastfeeding

• Safety has not been demonstrated in pregnancy, but should be administered if indicated

• May be administered the patient is breastfeeding. Advise the patient to stop breastfeeding and seek further advice form their lead maternity carer or GP

Fentanyl - Dosage

• IV bolus for analgesia:

  • 10-50 mcg every five mins for adult, as required. Use dose at the lower end of the range if patient is frail or has signs of shock

  • See paediatric drug dose tables for child

• IV infusion:

  • Start at 1 mcg/kg/hour, up to a maximum of 150 mcg/hour

  • Administer additional blouses as required, every five mins

  • Adjust infusion rate as required, every 15-20 mins

• IV for autonomic dysreflexia:

  • 20-30 mcg increments to a total of 100 mcg

• IN for analgesia:

  • 100 mcg for an adult

  • See paediatric drug dose tables for a child

  • Halve the dosage if patient is frail or has signs of shock

  • Repeat as required every 20 mins

• IM and SC for analgesia:

  • 50-100 mcg IM/SC for an adult

  • See paediatric drug dose tables for a child

  • Halve the dose if the patient is frail or has signs of shock

  • Repeat as required, every 20 mins, up to a maximum of three doses

• IV for RSI: refer to RSI guideline

• IV for sedation post intubation: refer to post intubation guideline

Fentanyl - Administration

• The preferred route for administration is IV

• IV boluses for analgesia:

  • Dilute 100 mcg to a total of 10 ml using 0.9% sodium chloride for an adult or a child whose weight has been rounded up to 30 kg or more. This final solution contains 10 mcg/ml

  • Dilute 100 mcg to a total of 100 ml using a 100 ml bag of 5% glucose for a child whose weight has been rounded up to 20 kg or less. This final solution contains 1 mcg/ml

• IN administration:

  • Draw it up undiluted, placing half of the total dose into two separate 1 ml syringes. When drawing up the first syringe, draw up an additional 0.1 ml of the drug over and above the planned volume and expel this slowly through the mucosal atomiser in order to fill the dead space. This does not need to be done with subsequent doses

• IM administration:

  • Administer undiluted. The preferred IM site is the lateral thigh. If this ite is not suitable, use the lateral upper arm.

• SC administration:

  • Administer undiluted subcutaneously into the abdominal wall

  • There is no need to sterilise the skin at the site of injection unless the skin is visibly contaminated

  • There is no need to sterilise the skin at the site of injection unless the skin is visibly contaminated

  • Pinch a fold of skin over the anterior abdominal wall between thumb and forefinger. Introduce the entire length of the needle using a dart technique and inject

Fentanyl - Common Adverse Effects

• Respiratory depression

• Bradycardia

• Hypotension

• Sedation

• Nausea and vomiting

• Itch

• Euphoria

Fentanyl - Usual Onset of Effect

• IV: 2-5 mins. The maximal analgesic and respiratory depressant effect may not occur until 10-15 mins and this may be longer in the elderly

• IN: 5-10 mins

• IM/SC: 5-10 mins

Fentanyl - Usual Duration of Effect

• 30-60 mins

• The effect on respiratory may last for several hours

Fentanyl - Usual Preparation

• Ampoule containing 100 mcg in 2 ml

Fentanyl - Pharmacokinetics

• It is more lipophilic (fat soluble) than morphine, which is why it is well absorbed through the nasal mucosa

• May cause a small amount of histamine release, in combination with pain relief that usually results in a small fall in blood pressure

• Is metabolised in the liver

• There are not significant effects from liver impairment on acute administration

Fentanyl - Common Interactions

• The effects will be increased in the presence of other opiates and sedatives

Fentanyl - Additional Information

• A patient administered the drug must be given a clear recommendation to be transported to a medical facility by ambulance, unless the patient is being treated using the “care during the last days of life” “patella dislocation” or “shoulder dislocation” guidelines

• Transport should usually be to an ED unless it is appropriate for the patient to be transported to a primary care facility

• Is usually the preferred opiate if:

  • The patient requires analgesia for a short period of time, or

  • The patient has renal impairment, or

  • The patient has signs of shock

Hydrocortisone - Mechanism of Action

• A corticosteroid with anti-inflammatory and immunosuppressant actions. It inhibits the production of inflammatory mediators, including prostaglandins and leukotrines, resulting in a reduction in the inflammatory and immune response.

Hydrocortisone - Indications

• Adults with angioedema occuring during inter-hospital transfer for stroke clot retrieval

• At risk of adrenal crisis or suspected to have adrenal crisis

• Severe or immediately life-threatening asthma

• Severe COPD or imminent respiratory arrest from COPD

Hydrocortisone - Contraindications

• Known severe allergy

Hydrocortisone - Cautions

• N/A

Hydrocortisone - Use in pregnancy or when breastfeeding

• Safety has not been demonstrated during pregnancy. However, there is significant clinical experience with steroids, they appear to be safe and this drug should be administered if indicated

• May be administered if the patient is breastfeeding. Advise the patient to stop breastfeeding and seek further advice from their lead maternity carer or GP

Hydrocortisone - Dosage

• 100 mg for an adult

• See paediatric drug dose table for a child

Hydrocortisone - Administration

• Press down on the plastic cap to force the diligent into the vial

• Mix the solution by turning the vial upside down several times. Do not shake the vial

• Remove the central plastic cap and draw up the contents

• For IV administration:

  • Dilute to approximately 10 ml using 0.9% sodium chloride and administer over 1-2 mins

• For IM administration:

  • Do not further dilute after reconstitution. The preferred IM site is the lateral thigh. If this site is not suitable use the lateral upper arm

Hydrocortisone - Common Adverse Effects

• Fatigue

• Sodium and water retention. This may worsen hypertension and heart failure, but is usually only of clinical significance with repeated and/or prolonged dosing

Hydrocortisone - Usual Onset of Effect

• 10-20 mins

Hydrocortisone - Usual Duration of Effect

• 8-12 hours

Hydrocortisone - Usual Preparation

• Vial with two chambers, one containing 100 mg of powder and the other containing 2 ml of sterile water for reconstitution

Hydrocortisone - Pharmacokinetics

• Metabolised in the liver

• Clearance is prolonged if the patient has significant liver impairment, but this does not alter the initial (loading) dose

Hydrocortisone - Common Interactions

• N/A