Paramedicine 2nd year drugs

Paracetamol

Indications:

• mild pain relief or analgesia combo with others

• headache

Contraindications:

• children < 1 month of age

Precautions:

• hepatotoxicity can occur with overdose

• risk of hepatotoxicity increases with: impaired hepatic function or liver disease, elderly/frail patients, malnourishment

Adverse effects:

• hypersensitivity reactions including severe skin rashes

• haematological reactions

• hypotension reported wiht IV infusion particularly in critically ill patients

Mechanism of Action:

• analgesic and antipyretic - exact mechanism unclear but thought to inhibit prostaglandin synthesis in CNS

Administration:

• 500mg tablets, max dose 1000mg, oral route

Methoxyflurane

Indications:

• analgesia

Contraindications:

• Pre-existing renal disease

• known (or genetic susceptibility) to malignant hyperthermia

Precautions:

• should not be administer more than 6mL in 24hrs due to increased risk of nephrotoxicity

• to limit occupational exposure, should not be administered in confined space. ensure adequate ventilation and place used inhalers in closed plastic bag when not in use

Adverse effects:

• dizziness, drowsiness, hypotension, N+V

Administration:

• 3mL bottle, self administered via inhaler, max dose 6mL

Fentanyl

Indications:

• analgesia

Contraindications:

• serotonin toxicity, MAOIs within the last 14 days, late second stage of labour

Precautions:

• elderly/frail, impaired hepatic function, respiratory depression, current asthma presentation, rhinitis, rhinorrhoea or facial trauma (IN)

Adverse effects:

• Bradycardia, respiratory depression, rigidity or diaphragm and intercostal muscles, N+V, rash, erythema

Mechanism of Action:

• mainly acts on mu-opioid receptors in the CNS to reduce transmission of pain impulse and by modulating descending inhibitory pathways from the brain.

Administration:

• 100mcg in 2mL ampoule, IN 100mcg max dose 400mcg, IV 50mcg max dose 200mcg, dilute 100mcg with 8mL normal saline to 10mL.

Morphine

Indications:

• analgesia

Contraindications:

• history of hypersensitivity, renal impairment/failure, late second stage of labour.

Precautions:

• elderly/frail, hypotension, respiratory depression, current asthma, resp tract burns, known opioid addiction, acute alcoholism, patient on MAOIs

Adverse effects:

• drowsiness, resp depression, euphoria, N+V, addiction, pin point pupils, hypotension, bradycardia.

Administration:

• 10 mg in 1mL in ampoule, IV 5mg max dose 20mg, dilute 1mL with 9mL normal saline. IM 10mg, repeat with 5mg 15 mins later once only.

Ketamine

Indications:

• intubation, analgesia, sedation

Contraindications:

• nil

Precautions:

• may exacerbate cardiovascular conditions

Adverse effects:

• hypertension, tachycardia, emergence reactions (confusion, hallucinations etc.), increased skeletal muscle tone, transient respiratory depression and apnoea (rare), N+V, injection site pain, lacrimation, hypersalivation, diplopia, nystagmus

Administration:

• 75mg IN (0.75mL), add 0.1mL to this volume to account for MAD deadspace, repeate 50mg at 20 min intervals

• presents as 200mg in 2mL ampoule

Ondansetron

Indications:

• undifferentiated N+V

• prophylaxis where vomiting could be clinically detrimental e.g. spinally immobilised, penetrating eye trauma.

Contraindications:

• apomorphine

Precautions:

• 1^st trimester pregnancy, congenital long QT syndrome, severe hepatic disease, ondansetron ODT may contain aspartame which should be avoided in patients with phenylketonuria

Adverse effects:

• headache, dizziness, QT prolongation, constipation, visual disturbance

Mechanism of action:

• 5-HT3 antagonist - exact mechanism of action is not fully understood. release of serotonin is thought to trigger a vomiting reflex in both peripheral and central nervous system

Administration:

• 4mg ODT; 8mg in 4ml glass ampoule, max dose 8 ml

Prochlorperazine

Indications:

• N+V in patients 21 and over, specifically for known allergy or C/I to ondansetron, vestibular nausea

• headache

Contraindications:

• CNS depression

• patients under 21

Precautions:

• elderly patients

• parkinson’s disease

Adverse effects:

• sedation, blurred vision, postural hypotension, QT prolongation, extrapyramidal reactions

Administration:

• 12.5mg in 1mL glass ampoule, IM single dose

Aspirin

Indications:

• ACS

Contraindications:

• Hypersensitivity to aspirin/salicylates, actively bleeding peptic ulcers, bleeding disorders, suspectid dissecting aortic aneurysm, chest pain associated with psychostimulant OD if SBP >160 mmHg

Precautions:

• peptic ulcer, asthma, patients on anticoagulants

Adverse effects:

• heartburn, nausea, GI bleeding, increased bleeding time, hypersensitivity reactions

Administration:

• 300mg oral tablet single dose

Glyceryl Trinitrate

Indications:

• chest pain in ACS, hypertension associated with ACS, cardiogenic APO, autonomic dysreflexia, preterm labour

Contraindications:

• BP <100mmHg, HR >150, HR< 50 except in autonomic dysreflexia, VT, PDE5 inhibitors, riociguat, bleeding in pregnancy.

Precautions:

• use lower doses in elderly patients, have no previous exposure to GTN or with recent MI, right ventricular MI or inferior STEMI with systolic BP < 160mmHg, preterm labour, avoid skin contact with concentrated solution.

Adverse effects:

• hypotension, tachycardia, bradycardia, headache, dizziness, syncope, skin flushing.

Administration:

• 300mcg tablet, 50mg patch (releases 0.4/hr)

• sublingual, place tablet under tongue allow to dissolve

• transdermal, write date/time on patch and apply to chest or upper arm

Adrenaline

Indications:

• anaphylaxis, asthma, bradycardia with poor perfusion, cardiac arrest, croup, shock, oroligual oedema secondary to tPA infusion.

Contraindications:

• nil

Precautions:

• hypovolaemia - provide fluid prior to administering adrenaline, elderly/frail, MAOIs, TCAs, beta blockers, quetiapine toxicity.

Adverse effects:

• arrhythmia, palpitations, hypertension, angina, headache, anxiety, tremor, hyperglycaemia

Mechanism of action:

• a1 adrenergic agonist, b1 adrenergic agonist, b2 adrenergic agonist, mast cell stabilisation

Administration:

• 1mg in 1 mL and 1mg in 10mL, IM, IV, Neb etc.

Ceftriaxone

Indications:

• meningococcal septicaemia, sepsis where transport time is over 60 mins

Contraindications:

• cephalosporin allergy

• preterm neonates

Precautions:

• penicillin allergy

Adverse effects:

• diarrhoea, N+V, irritation at injection site, rash

Mechanism of action:

• interferes with bacterial cell wall peptidoglycan synthesis by binding to penicillin binding proteins leading to cell lysis and death

Administration:

• 1g vial: dilute with 3.5 mL lidocaine 1% to 4mL, administer into upper thigh IM, 1g vial dilute with 9.5mL water for injection to 10 ml, administer total dose over 4 mins.

Dexamethasone

Indications:

• anaphylaxis associated with bronchospasm, asthma, copd, severe COVID19, croup, non-foreign body obstruction stridor (adult)

Contraindications:

• nil

Precautions:

• nil

Adverse effects:

• nil

Administration:

• 8mg in 2ml, IM, IV, oral, 8mg single dose.

Ipatropium Bromide

Indications:

• Anaphylaxis associated bronchospasm, asthma severe. lifethreatening, COPD

Contraindications:

• nil

Precautions:

• avoid contact with eyes, cardiovascular disorders

Adverse effects:

• palpitations, tachycardia (rare), nausea, dizziness, headache,

Administration:

• 250mcg 1ml nebule.

• single dose 500mcg neb 2ml

Salbutamol

Indications:

• anaphylaxis with associated bronchospasm, asthma, COPD, hyperkalaemia, oleoresin capsicum spray exposure with associated bronchospasm, smoke inhalation with associated bronchospasm

Contraindications:

• nil

Precautions:

• <2 years old, cardiogenic APO, large doses may cause hypokalaemia, hyperglycaemia, metabolic acidosis

Adverse effects:

• palpitations, tachycardia, headache, muscle tremors

Mechanism of action:

• beta adrenergic stimulant with primarily beta 2 effects, promotes bronchodilation, activates sodium-potassium pumps shifting potassium into cells

Administration:

• 10mg neb for severe/lifethreat then repeat 5mg 5/60, 400-1200mcg PMDI 4-12 puffs, repeat 20/60

Glucagon

Indications:

• hypoglycaemia bgl <4mmol/L with altered conscious state or unresponsive to oral glycaemic agents where IV access unable to be obtained, OR anaphylaxis with persistent hypotension after two doses of adrenaline where patient has a history of heart failure or is taking beta blockers.

Contraindications:

• known pancreatic tumours, known phaeochromocytoma (tumour of adrenal gland)

Precautions:

• may have reduced affect with adrenal insufficiency, alcohol induced hypoglycaemia, prolonged exercise, recent administration of glucagon, chronic liver disease, ketogenic diets and patients with frequent episodes of hypoglycaemia. If administering glucagon patient should be managed laterally to mitigate risk of N+V secondary to administration

Adverse effects:

• N+V

Administration:

• vial containing 1mg of glucagon hydrochloride with glass syringe containing 1mL of water for injection, IV IM. For anaphylaxis repeat once at 5mins if req’d

Oxygen

Indications:

• SpO2 <92% or SpO2 < 88% if risk of hypercapnic resp failure

Contraindications:

• nil

Precautions:

• excessive oxygen may be harmful to patients at risk of hypercapnic resp failure (COPD, neuromuscular disorders, cystic fibrosis, bronchiectasis, severe kyphosis, obesity) titrate oxygen to SpO2 of 88-92%

Adverse effects:

• nil

Mechanism of action:

• delivers supplemental oxygen when the patient cannot breathe enough on room air

Administration:

• nasal canula 2-4L/min, non rebreather 10-15L/min

Amiodarone

Indications:

• VF / Pulseless VT refractory to defibrillation

• sustained or recurrent VT

Contraindications:

• tricyclic antidepressant toxicity

• QT > 500 milliseconds

• VT following ondansetron administration

• pregnancy

Precautions:

• older patients more susceptible to bradycardia post-infusion

Adverse effects:

• rebound bradycardia, hypotension, phlebitis

• nausea, vomiting, metallic taste

Presentation:

150mg in 3mL ampoule, IV/IO, 300mg initial dose, repeat with 150 mg if VF / VT persists (MAX 450mg total)

Lidocaine

Indications:

• Local anaesthetic to reduce pain associated with IM administration of ceftriaxone

• VF / pulseless VT refractory to defib.

Contraindications:

• known sensitivity to lidocaine or related local anaesthetics (ending in caine)

Precautions:

• IM and local infiltration - inadvertant intravascular administration may result in systemic toxicity

• IO - impaired CV function

Adverse effects:

• allergic reactions are rare and may present as localised oedema, urticaria, bronchospasm, and anaphylaxis

• signs of systemic toxicity include: tinnitus, blurred vision, sudden chance in conscious state, agitation, convulsions, hypotension, bradycardia, arrhythmias, cardiac arrest

Presentation:

50mg in 5mL amp

IM for ceftriaxone dilution, 1g vial: 3.5mL lidocaine 1% to 4mL. Dilute with 7mL lidocaine to 8ml, administer each 1g seperately.

Normal Saline

Indications:

• fluid replacement e.g. hypovolaemia, to expand intravascular volume, ege anaphylaxis, burns, sepsis, fluid challenge in unresponsive hypotensive patients, fluids for diluting and administering IV drugs, fluid for TKVO and IV admin of emergency drugs

Contraindications:

• nil

Precautions:

• nil

Adverse effects:

• nil

Mechanism of action:

• increases volume of intravascular compartment

Administration:

• IV or IO