blocks vagal reflexes which mediate bronchoconstriction
possibly more effective when used in combination with salbutamol
Onset - 3-5 minutes
Duration 2-4 hours
What is ipratropium bromide used for?
Bronchospasm of any cause - used as an adjunct to salbutamol.
What is possible adverse effects of ipratropium bromide?
Rare with single use - occasional urinary retention
What are the precautions of ipratropium bromide use?
Care with patients with glaucoma
What is the dose of Ipratropium bromide?
Adult - 500mcg mixed with 1st/3rd/5th... dose of salbutamol.
or 4 x 21mcg (4 puffs) with MDI
Paediatrics - 250mcg mixed with 1st/3rd/5th ... dose of salbutamol
or 2 x 21mcg (2 puffs) with MDI
When should you use the MDI/spacer?
For mild - moderate respiratory distress, no hypoxia and familiar with use.
What type of drug is methoxyflurane?
Volatile inhalation anaesthetic and analgesic agent.
What is the presentation of methoxyflurane?
What is the action of methoxyflurane?
Central Nervous system depressant
Onset: 3-5 minutes
Offset: 3-5 minutes
What is the indication for methoxyflurane use?
Pain of all origins.
What are the possible adverse effects of methoxyflurane use?
(all rare with once only ambulance use)
What are the contraindications of methoxyflurane use?
Depressed LOC (GCS <13)
What precautions should be considered before using methoxyflurane?
anti-biotic or barbiturate use
caution if unable to self administer
What is the dose of methoxyflurane?
3mls self administered (inhaled) using penthrox inhaler with up to 8lpm of oxygen
Repeat x 1 as required
Dose should not exceed 6ml /day or 15mls/week
What type of drug is metoclopramide (Maxolon) ?
What is the presentation of maxolon?
10mg in 2ml ampoule
What is the action of maxolon?
Antiemetic - acting centrally on the brain stem increasing gastric emptying
Onset - 3-15mins IV
Duration - 30 minutes
What is Maxolon used for?
Prevent vomiting when:
when narcotic analgesic is to be administered
high spinal injury
serious eye injury
suspected ischemic chest pain
Treat nausea and vomiting
What are the possible adverse effects of maxolon use?
(Uncommon with usual dose) Occasionally
oculogyric crisis/facial spasms
What are the contraindications of maxolon use?
Known hypersensitivity (previous reaction)
What is the dose of maxolon?
Adult - 10mg IV over 2 minutes
or 10mg IM
Paediatrics not used.
Single dose only.
What type of drug is midazolam?
Anti-convulsant and sedative agent
What is the presentation of midazolam?
5mg in 5ml ampoule
15mg in 3ml ampoule
What are the actions of midazolam?
Anticonvulsant - reduces seizure activity
Onset: (IV) 1-5 mins Duration 2-3 hours
Onset (IM) 2-5 mins Duraiton ?2-3 hours
What is Midazolam used for?
Status Epilepticus - in a patient who has continual or prolonged seizures.
sedation to manage airway, RSI, sedation of previously intubated patient
Adjunct to analgesia for injuries where significant muscle spasm is presentTo manage agitated and combative patients
To manage autonomic hyperreflexia
What are the possible adverse effects of midazolam?
Depression of level of consciousness which may lead to:
loss of airway control
What are the contraindication of midazolam use?
What precautions should be considered with midazolam use?
What is the dose of Midazolam for seizures?
Adult Dose: 0.1mg/kg IM repeat x 1 after 10 minutes as necessary
Up to 0.1mg/kg IV over 2minutes until fitting ceases. Repeat is fitting continues or recurs.
Paeds Dose: 0.1mg/kg IM - repeat x1 after 10 minutes as necessary.
Up to 0.1mg/kg IV over 2 minutes until fitting ceases. Repeat if fitting continues or recurs.
What type of drug is Morphine Sulphate?
Narcotic analgesic (S8)
What is the presentation of morphine?
10mg in 1 ml ampoule
What are the actions of Morphine?
Decreases pain perception and anxiety.
Onset: (IV) 2-5 minutes = Duration: 1-2 hours
Onset: (IM) 5+ minutes = Duration: 2-3 hours
What is the indication for the use of Morphine?
To relieve severe pain
Acute pulmonary oedemaRSI
Sedation of previously intubate patient
What are the possible adverse effects of Morphine use?
Nausea and vomiting
What are the contraindications for Morphine use?
Depressed Level of consciousness (GCS<13) --> pain relief only
Respiratory Depression --> pain relief only
BP <770mmHg --> pain relief only
BP <90mmHg --> APO
Acute Asthma attacks
What precautions need to be considered before Morphine administration?
Elderly patients (may be sensitive)
Patients with COPD
Hypovolaemic patients (hypovolaemia should be corrected BEFORE morphine administration)
Patients with systolic BP 70-90mmHg
Children under 1 year old
Pain management in labour
What is the dose of Morphine for pain relief?
Adult: Up to 0.05mg/kg IV over 2 minutes
May be repeated at 5 minute intervals (up to a maximum of 3x maximum calculated dose) until pain is managed. UNLESS pt BP <90mmHg [half calculated dose and fluids]
Paeds: Up to 0.05mg/kg IV over 2 minutesMay be repeated at 5 minute intervals (up to a maximum of 3x maximum calculated dose) until pain is managed. UNLESS pt BP <70mmHg [half calculated dose and fluids]
Use with caution if under 1 y/o
Morphine can be used alternatively with Ketamine
When can/should Morphine be administered IM?
Pain relief ONLY (NOT FOR ISCHEMIC CHEST PAIN)
If no IV is available
Patient contact is estimated >20 minutes
What is the dose of IM Morphine?
(Pain relief only) NOT FOR CHEST PAIN
Repeat x1 after 30-45 minutes as required
What is the altered dose of Morphine for patients with 70mmHh >BP < 90mmHg?
IV use only!
hypovolemic patients must be receiving fluids
up to half calculated (0.05mg/kg) given SLOWLY
may be repeated as required with great care, and with appropriate interval b/w dose.
No further doses if BP drops 10mmHg or more with half dose (even if remains >70mmHg)
What is the dose of morphine for pulmonary oedema?
0.05mg/kg IV over 2 minutes
May be repeated x 1 after 10 minutes if required.
What is the dose of Morphine for a) maintenance of sedation post intubation? and b) when used with midazolam for RSI?
a) 0.05 mg/kg IV SLOWLY
b) Adult : 10mg IV fast push (dose adjusted for weight, age and BP) --> Paeds: 0.05mg/kg rapid push = repeat x 1 if required.
What are some special note that should be considered for morphine?
A drug of dependence - must be checked by both members.
Under the Drugs of Dependence Act, recording and accounting for its use is a legal requirement
The unused portion of the dose must be appropriately disposed of and its disposal recorded.
Side effects may be reversed by Naloxone, although it is desirable to avoid unless absolutely necessary
Advanced age may be a better indicator of dose size than weight in the elderly.
What type of drug is Naloxone?
What are the actions of naloxone?
Reverses the effects of narcotic analgesics.
Onset (IV) 1-2 minutes
Duration 30-45 minutes
IM - unknown, but suspected to be longer than IV.
What are the indications for Naloxone use?
drug overdose and poisoning
Use in situations where there is significant decrease in level of consciousness where there is hypoventilation, and/or loss of protective reflexes and where overdose of narcotics cannot be excluded.
What are the possible adverse effects of naloxone use?
may precipitate acute withdrawal syndrome in narcotic addicts
occasional aggressive behaviour following reversal
nausea and vomiting
What are the contraindications of naloxone use?
What is the dose of Naloxone?
AP : 800mg IM --> single dose only
Paeds IM --> 0.01mg/kg.
ICP: 0.4mg IM then 0.4mg IV increments fast push--> may repeat IV dose x 3 (to max of 2mg)
Paeds - 0.01mg IV fast push (max 3 doses)
ALL doses may be given IM or IV as situation demands.
What should be considered when treating a person with Naloxone? (Special notes)
IV may rapidly wear off - if pt likely to refuse tx an IM dose is highly recommended.
Special care is needed if long-acting agents are known or suspected to have been used. Larger IM dose and transport to hospital is recommended.
What is contained in normal saline?
0.9% sodium chloride solution - containing 151mMol sodium and 151mMol chloride per litre.
What are the actions of Normal Saline?
Plasma volume expander
expands interstitial fluid volume
plasma volume effect is only temporary as most of the saline moves out of the blood vessels quickly.
What are the indications for normal saline use?
Initial fluid replacement, in volume depleted or dehydrated patients. Volume depletion may be due to loss of blood, plasma, fluid or electrolytes.
Maintainance of hydration during prolonged patient contact time
TKVO as IV route for drugs.
What are the adverse effects of normal saline use?
What is the dose of Normal saline?
IV FLUID RESUSCITATION: Adult: 10 ml/kg lV – then reassess patient
Aim to keep BP at about 90mmHg systolic.
Haemorrhagic hypovolaemia aim to keep BP 80-90 systolic.
TBI aim for >100 systolic.
No limit on amount, dependent on condition of patient.
Paediatric: 10 ml/kg lV or IO – then reassess patient
Paediatric cardiac arrest: 20 ml/kg
Adult & Paed: Sepsis & Anaphylaxis 20mls/kg IV or IO
TKVO: Adult and Paediatric:
10 drops per minute (30ml/hr with a standard drip set).
What is the action of Obidoxime?
Treat super toxic organophosphate poisoning by relieving the symptoms of skeletal neuromuscular blocking that occurs during a chollinergic crisis.
Used in combination with atropine, in auto injector or with atropine separately administered
What are possible adverse effects of obidoxime use?
Hypotension, menthol like sensation, warm feeling to face.
Dull feeling to site of injection
What is the dose of obidoxime?
Adult - Up to 660mg IM over 30 minutes (3 doses via auto injector)
Paeds - 220mg IM (1 dose only)
Preffered site is upper thigh
Injector must be held in place for 10 seconds to ensure full dose administered.