Drugs 4 Paramedic Students - CPG 2015 Update Edition

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Drugs 4 Paramedic Students - CPG 2015 Update Edition
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2015-04-26 12:30:41
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Drugs Paramedic Students CPG 2015 Update Edition
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  1. Adrenaline - Presentation
    • 1 mg in 1 mL glass ampoule (1:1,000)
    • 1 mg in 10 mL glass ampoule (1:10,000)
  2. Adrenaline - Pharmacology & Metabolism
    • A naturally occurring alpha and beta-adrenergic stimulant
    • Actions:
    • - Increases HR by increasing SA node firing rate (Beta 1)
    • - Increases conduction velocity through the A-V node (Beta 1)
    • - Increases myocardial contractility (Beta 1)
    • - Increases the irritability of the ventricles (Beta 1)
    • - Causes bronchodilatation (Beta 2)
    • - Causes peripheral vasoconstriction (Alpha)

    • Metabolism by monoamine oxidase and other enzymes in the blood, liver and around nerve
    • endings; excreted by the kidneys
  3. Adrenaline - Primary emergency indications
    • 1. Cardiac arrest - VF/VT, Asystole or PEA
    • 2. Inadequate perfusion (cardiogenic or non-cardiogenic/non-hypovolaemic)
    • 3. Bradycardia with poor perfusion
    • 4. Anaphylaxis
    • 5. Severe asthma - imminent life threat not responding to nebulised therapy, or
    • unconscious with no BP
    • 6. Croup
  4. Adrenaline - Contraindication
    1. Hypovolaemic shock without adequate fluid replacement
  5. Adrenaline - Precautions
    • Consider reduced doses for:
    • 1. Elderly / frail Pts
    • 2. Pts with cardiovascular disease
    • 3. Pts on monoamine oxidase inhibitors

    4. Higher doses may be required for Pts on beta blockers
  6. Adrenaline - Side effects
    • 1. Sinus tachycardia
    • 2. Supraventricular arrhythmias
    • 3. Ventricular arrhythmias
    • 4. Hypertension
    • 5. Pupillary dilatation
    • 6. May increase size of MI
    • 7. Feeling of anxiety/palpitations in the conscious Pt
  7. Adrenaline - Special notes
    • IV Adrenaline should be reserved for life threatening situations.
    • IV effects:
    • Onset: 30 sec
    • Peak: 3 – 5 min
    • Duration: 5 – 10 min

    • IM effects:
    • Onset: 30 – 90 sec
    • Peak: 4 – 10 min
    • Duration: 5 – 10 min
  8. Aspirin - Presentation
    • 300 mg chewable tablets
    • 300 mg soluble or water dispersible tablets
  9. Aspirin - Pharmacology
    An analgesic, antipyretic, anti-inflammatory and antiplatelet aggregation agent

    • Actions:
    • - To minimise platelet aggregation and thrombus formation in order to retard the
    • progression of coronary artery thrombosis in ACS
    • - Inhibits synthesis of prostaglandins - anti-inflammatory actions
  10. Aspirin - Metabolism
    Converted to salicylate in the gut mucosa and liver; excreted mainly by the kidneys
  11. Aspirin - Primary emergency indication
    1. ACS
  12. Aspirin - Contraindications
    • 1. Hypersensitivity to aspirin / salicylates
    • 2. Actively bleeding peptic ulcers
    • 3. Bleeding disorders
    • 4. Suspected dissecting aortic aneurysm
    • 5. Chest pain associated with psychostimulant OD if SBP >160 mmHg
  13. Aspirin - Precautions
    • 1. Peptic ulcer
    • 2. Asthma
    • 3. Pts on anticoagulants
  14. Aspirin - Side effects
    • 1. Heartburn, nausea, gastrointestinal bleeding
    • 2. Increased bleeding time
    • 3. Hypersensitivity reactions
  15. Aspirin - Special notes
    Aspirin is C/I for use in acute febrile illness in children and adolescents

    • The anti-platelet effects of Aspirin persist for the natural life of platelets.
    • Onset: n/a
    • Peak: n/a
    • Duration: 8 - 10 days
  16. Ceftriaxone - Presentation
    1 g sterile powder in a glass vial
  17. Ceftriaxone - Pharmacology & Metabolism
    • P - Cephalosporin antibiotic
    • M - Excreted unchanged in urine (33% - 67%) and in bile
  18. Ceftriaxone - Primary emergency indication
    • 1. Suspected meningococcal septicaemia
    • 2. Severe sepsis (consult only)
  19. Ceftriaxone - Contraindication
    1. Allergy to Cephalosporin antibiotics
  20. Ceftriaxone - Precautions
    1. Allergy to Penicillin antibiotics
  21. Ceftriaxone - Side effects
    • Nausea
    • Vomiting
    • Skin rash
  22. Ceftriaxone - Special notes
    • Usual dose: adult 1 g, child 50 mg/kg (max. 1 g)
    • Ceftriaxone IV must be made up to 10 mL using sterile water and
    • dose administered over 2 min
    • Ceftriaxone IM must be made up to 4 mL using 1% Lignocaine and
    • dose administered in lateral upper thigh
    • IM/IV effects:
    • Onset: n/a
    • Peak: n/a
    • Duration: n/a
  23. Fentanyl - Presentation
    • 100 mcg in 2 mL glass ampoule
    • 200 mcg in 1mL glass vial (IN use only)
    • 600 mcg in 2 mL glass vial (IN use only)
  24. Fentanyl - Pharmacology
    • A synthetic opioid analgesic
    • Actions:
    • CNS effects:
    • - Depression – leading to analgesia
    • - Respiratory depression – leading to apnoea
    • - Dependence (addiction)

    • Cardiovascular effects:
    • - Decreases conduction velocity through the A-V node
  25. Fentanyl - Metabolism
    By the liver; excreted by the kidneys
  26. Fentanyl - Primary emergency
    indications
    • 1. Sedation to facilitate intubation
    • 2. Sedation to maintain intubation
    • 3. Drug facilitated intubation
    • 4. Analgesia – IV/IN
  27. Fentanyl - Contraindication
    1. Known hypersensitivity
  28. Fentanyl - Precautions
    RICEPRK

    • 1. Respiratory depression, e.g. COPD
    • 2. Impaired renal / hepatic function
    • 3. Current asthma
    • 4. Elderly/frail patients
    • 5. Pts on monoamine oxidase inhibitors
    • 6. Rhinitis, rhinorrhea or facial trauma (IN route)
    • 7. Known addiction to opioids
  29. Fentanyl - Side effects
    RARB

    • Respiratory depression
    • Apnoea
    • Rigidity of the diaphragm and intercostal muscles
    • Bradycardia
  30. Fentanyl -
    • Fentanyl is a Schedule 8 drug under the Poisons Act and its use must be carefully
    • controlled with accountability and responsibility

    Respiratory depression can be reversed with Naloxone

    100 mcg Fentanyl is equivalent in analgesic activity to 10 mg Morphine

    • IV effects:
    • Onset: Immediate
    • Peak: < 5 min
    • Duration: 30 - 60 min

    • IN effects:
    • Peak: 2 min
  31. Glyceryl Trinitrate (GTN) - Presentation
    • 0.6 mg tablets
    • Transdermal GTN Patch (50 mg 0.4 mg/hr release)
  32. Glyceryl Trinitrate (GTN) - Pharmacology
    Principally, a vascular smooth muscle relaxant

    • Actions:
    • - Venous dilatation promotes venous pooling and reduces venous return to the heart
    • (reduces preload)
    • - Arterial dilatation reduces systemic vascular resistance and arterial pressure
    • (reduces afterload)
    • The effects of the above are:
    • - Reduced myocardial O2
    • demand
    • - Reduced systolic, diastolic and mean arterial blood pressure, whilst usually
    • maintaining coronary perfusion pressure
    • - Mild collateral coronary arterial dilatation may improve blood supply to ischaemic
    • areas of myocardium
    • - Mild tachycardia secondary to slight fall in blood pressure
    • - Preterm labour: Uterine quiescence in pregnancy
  33. Glyceryl Trinitrate (GTN) - Primary emergency indication
    • 1. Chest pain with ACS
    • 2. Acute LVF
    • 3. Hypertension associated with ACS
    • 4. Autonomic dysreflexia
    • 5. Preterm labour (consult)
  34. Glyceryl Trinitrate (GTN) - Contraindication
    • 1. Known hypersensitivity
    • 2. Sildenafil Citrate (Viagra) or Vardenafil (Levitra) administration in the previous24 hr or Tadalafil (Cialis) administration in the previous 4 days (PDE5 inhibitors)
    • 3. Systolic blood pressure < 110 mmHg tablet
    • 4. Systolic blood pressure < 90 mmHg patch
    • 5. Heart rate > 150 bpm
    • 6. Bradycardia HR < 50 bpm (excluding autonomic dysreflexia)
    • 7. VT
    • 8. Inferior STEMI with systolic BP < 160 mmHg
    • 9. Right ventricular MI
  35. Glyceryl Trinitrate (GTN) - Precautions
    • 1. No previous administration
    • 2. Elderly Pts
    • 3. Recent MI
    • 4. Concurrent use with other tocolytics
    • [Tocolytics (also called anti-contraction medications or labor repressants) are medications used to suppress premature labor]
  36. Glyceryl Trinitrate (GTN) - Side effects
    • Tachycardia
    • Hypotension
    • Headache
    • Skin flushing (uncommon)
    • Bradycardia (occasionally)
  37. Glyceryl Trinitrate (GTN) - Special notes (some selected only)
    • - Since both men and women can be prescribed Sildenafil Citrate (Viagra) or
    • Vardenafil (Levitra) or Tadalafil (Cialis) all Pts should be asked if and when they last
    • had the drug to determine if GTN is C/I

    • - Tadalafil (Cialis) may also be prescribed to men for Rx of benign prostatic
    • hypertrophy. This is a new indication for the drug and may lead to an increased
    • number of Pts under this Rx regimen.

    • Interhospital transfer:
    • The IV dose is to be prescribed and signed by the referring hospital medical officer.
    • Infusions usually run in the range of 5 mcg/min to 200 mcg/min and increased 3 - 5
    • mcg/min.

    • S/L effects:
    • Onset: 30 sec – 2 min
    • Peak: 5 - 10 min
    • Duration: 15 - 30 min

    • Intravenous effects
    • Onset: 30 sec – 1 min
    • Peak: 3 - 5 min
    • Duration: 15 - 30 min

    • Transdermal effect
    • Onset: Up to 30 min
    • Peak: 2 hr
  38. Ipratropium Bromide - Presentation
    250 mcg in 1 mL nebule or polyamp
  39. Ipratropium Bromide - Pharmacology
    Anticholinergic bronchodilator

    • Actions:
    • - Allows bronchodilatation by inhibiting cholinergic bronchomotor tone (i.e. blocks vagal reflexes which mediate bronchoconstriction
  40. Ipratropium Bromide - Metabolism
    Excreted by the kidneys
  41. Ipratropium Bromide - Primary emergency indication
    1. Severe respiratory distress associated with bronchospasm
  42. Ipratropium Bromide - Contraindication
    1. Known hypersensitivity to Atropine or its derivatives
  43. Ipratropium Bromide - Precautions
    • 1. Glaucoma
    • 2. Avoid contact with eyes
  44. Ipratropium Bromide - Side effects
    HANDS TP

    • Headache
    • Acute angle closure glaucoma secondary to direct eye contact (rare)
    • Nausea
    • Dry mouth
    • Skin rash
    • Tachycardia (rare)
    • Palpitations (rare)
  45. Ipratropium Bromide - Special notes
    • Ipratropium Bromide must be nebulised in conjunction with Salbutamol and is to be
    • administered as a single dose only.

    • Onset: 3 - 5 min
    • Peak 1.5 - 2 hr
    • Duration: 6 hr
  46. Methoxyflurane - Presentation & Pharmacology
    3 mL glass bottle

    • Pharma:
    • Inhalational analgesic agent at low concentrations
  47. Methoxyflurane - Metabolism
    • Excreted mainly by the lungs
    • By the liver
  48. Primary emergency indication
    1. Pain relief
  49. Methoxyflurane - Contraindication
    • 1. Pre-existing renal disease / renal impairment
    • 2. Concurrent use of tetracycline antibiotics
    • 3. Exceeding total dose of 6 mL in a 24 hr period
  50. Methoxyflurane - Precautions
    • 1. The Penthrox™ inhaler must be hand-held by the Pt so that if unconsciousness
    • occurs it will fall from the Pt’s face. Occasionally the operator may need to assist
    • but must continuously assess the level of consciousness
    • 2. Pre-eclampsia[Pre-eclampsia is a serious condition of pregnancy characterised by high blood pressure, protein in the urine and swelling of the hands, feet and face.]
    • 3. Concurrent use with Oxytocin may cause hypotension
  51. Methoxyflurane - Side effects
    • Drowsiness
    • Decrease in blood pressure and bradycardia (rare)
    • Exceeding the maximum total dose of 6 mL in a 24 hr period may lead to
    • renal toxicity
  52. Methoxyflurane - Special notes
    • The maximum initial priming dose for Methoxyflurane is 3 mL. This will provide
    • approximately 25 min of analgesia and may be followed by one further 3mL dose
    • once the initial dose is exhausted if required. Analgesia commences after 8 - 10
    • breaths and lasts for approximately 3 - 5 min once discontinued.

    Do not administer in a confied space. Ensure adequate ventilation in ambulance
  53. Metoclopramide - Presentation
    10 mg in 2 mL polyamp
  54. Metoclopramide - Pharmacology
    Antiemetic

    • Actions:
    • - Accelerates gastric emptying and peristalsis
    • - Dopamine receptor antagonist
  55. Metoclopramide - Metabolism
    By the liver; excreted by the kidneys
  56. Metoclopramide - Primary emergency indication
    • 1. Nausea / vomiting associated with
    • - Chest pain / discomfort of a cardiac nature
    • - Opioid administration for pain
    • - Cytotoxic or radiotherapy
    • - Previously diagnosed migraine
    • - Severe gastroenteritis

    • 2. Prophylaxis:
    • - Awake spinal immobilised Pts
    • - Eye trauma
  57. Metoclopramide - Contraindication
    • 1. Children
    • 2. Suspected bowel obstruction or perforation
    • 3. Gastrointestinal haemorrhage
  58. Metoclopramide - Side effects
    DLDME

    • Drowsiness
    • Lethargy
    • Dry mouth
    • Muscle tremor
    • Extrapyramidal reactions (usually the dystonic type)
  59. Metoclopramide - Special notes
    • Not effective for established motion sickness.
    • Not effective for nausea prophylaxis in the setting of opioid administration.

    • IV effects:
    • Onset: 1 – 3 min
    • Peak: n/a
    • Duration: 10 – 30 min
    • IM effects:
    • Onset: 10 – 15 min
    • Peak: n/a
    • Duration: 1 – 2 hr
  60. Midazolam - Presentation
    • 5 mg in 1 mL glass ampoule
    • 15 mg in 3 mL glass ampoule
  61. Midazolam - Pharmacology
    Short acting CNS depressant

    • Actions:
    • - Anxiolytic
    • - Sedative
    • - Anti-convulsant
  62. Midazolam - Metabolism
    In the liver; excreted by the kidneys
  63. Midazolam - Primary emergency indication
    • 1. Status epilepticus
    • 2. Sedation to enable intubation (RSI / IFS)
    • 3. Post intubation sedation
    • 4. Sedation to enable synchronised cardioversion
    • 5. Sedation in the agitated Pt (including Pts under the Mental Health Act 2014)
    • 6. Sedation in psychostimulant OD
  64. Midazolam - Contraindications
    1. Known hypersensitivity to benzodiazepines
  65. Midazolam - Precautions
    • 1. Reduced doses may be required for the elderly/frail, Pts with chronic renal failure,
    • CCF or shock
    • 2. The CNS depressant effects of benzodiazepines are enhanced in the presence of
    • narcotics and other tranquillisers including alcohol
    • 3. Can cause severe respiratory depression in Pts with COPD
    • 4. Pts with myasthenia gravis
  66. Midazolam - Side effects
    • Depressed level of consciousness
    • Respiratory depression
    • Loss of airway control
    • Hypotension
  67. Midazolam - Special notes
    • IM effects:
    • Onset: 3 – 5 min
    • Peak: 15 min
    • Duration: 30 min

    • IV effects:
    • Onset: 1 – 3 min
    • Peak: 10 min
    • Duration: 20 min
  68. Morphine - Presentation
    10 mg in 1 mL glass ampoule
  69. Morphine - Pharmacology
    • CNS effects:
    • - Depression (leading to analgesia)
    • - Respiratory depression
    • - Depression of cough reflex
    • - Stimulation (changes of mood, euphoria or dysphoria, vomiting, pin-point pupils)
    • - Dependence (addiction)

    • Cardiovascular effects:
    • - Vasodilatation
    • - Decreases conduction velocity through the A-V Node
  70. Morphine - Metabolism
    By the liver; excreted by the kidneys
  71. Morphine - Primary emergency indication
    • 1. Pain relief
    • 2. Acute LVF with shortness of breath and full field crackles
    • 3. Sedation to maintain intubation
    • 4. Sedation to enable intubation
    • 5. RSI
  72. Morphine - Contraindications
    • 1. Known hypersensitivity
    • 2. Late second stage of labour
  73. Morphine - Precautions
    EHRCRKAP

    • 1. Elderly/frail patients
    • 2. Hypotension
    • 3. Respiratory depression
    • 4. Current asthma
    • 5. Respiratory tract burns
    • 6. Known addiction to opioids
    • 7. Acute alcoholism
    • 8. Pts on monoamine oxidase inhibitors
  74. Morphine - Side effects
    • CNS effects:
    • - Drowsiness
    • - Respiratory depression
    • - Euphoria
    • - Nausea, vomiting
    • - Addiction
    • - Pin-point pupils

    • Cardiovascular effects:
    • - Hypotension
    • - Bradycardia
  75. Morphine - Special notes
    • Morphine is a Schedule 8 drug under the Poisons Act and its use must be
    • carefully controlled with accountability and responsibility.
    • Side effects of Morphine can be reversed with Naloxone.
    • Occasional wheals are seen in the line of the vein being used for IV injection. This is
    • not an allergy, only a histamine release.

    • IV effects:
    • Onset: 2 – 5 min
    • Peak: 10 min
    • Duration: 1 – 2 hr

    • IM effects:
    • Onset: 10 – 30 min
    • Peak: 30 – 60 min
    • Duration: 1 – 2 hr
  76. Naloxone - Presentation
    • 0.4 mg in 1 mL glass ampoule
    • 2 mg in 5 mL (prepared syringe)
  77. Naloxone - Pharmacology
    An opioid antagonist

    • Action:
    • - Prevents or reverses the effects of opioids
  78. Naloxone - Metabolism
    By the liver
  79. Naloxone - Primary emergency indication
    • 1. Altered conscious state and respiratory depression secondary to administration of
    • opioids or related drugs.
  80. Naloxone - Contraindications
    1. Nil of significance in the above indication
  81. Naloxone - Precautions
    • 1. If Pt is known to be physically dependent on opioids, be prepared for a combative
    • Pt after administration.
    • 2. Neonates.
  82. Naloxone - Side effects
    • Symptoms of opioid withdrawal:
    • - Sweating, goose flesh, tremor
    • - Nausea and vomiting
    • - Agitation
    • - Dilatation of pupils, excessive lacrimation
    • - Convulsions
  83. Naloxone - Special notes
    • Naloxone reverses the effects of opioids with none of the actions produced by other
    • opioid antagonists when no opioid is present in the body. (For example, it does not
    • depress respiration or cause pupillary constriction). In the absence of opioids, Naloxone has no perceivable effects.

    • Following an opioid associated cardiac arrest Naloxone should not be administered.
    • Maintain assisted ventilation.

    Following head injury Naloxone should not be administered. Maintain assisted ventilation if required.

    • IV effects:
    • Onset: 1 – 3 min
    • Peak: n/a
    • Duration: 30 – 45 min
    • IM effects:
    • Onset: 1 – 3 min
    • Peak: n/a
    • Duration: 30 – 45 min
  84. Prochlorperazine (Stemetil) - Presentation
    12.5 mg in 1 mL glass ampoule
  85. Prochlorperazine (Stemetil) - Primary emergency indication
    • 1. Rx or prophylaxis of nausea / vomiting for
    • - Motion sickness
    • - Planned aeromedical evacuation
    • - Known allergy or C/I to Metoclopramide administration
    • - Headache irrespective of nausea / vomiting
    • - Vertigo
  86. Prochlorperazine (Stemetil) - Contraindications
    • 1. Circulatory collapse
    • 2. CNS depression
    • 3. Previous hypersensitivity
    • 4. Children
  87. Prochlorperazine (Stemetil) - Precautions
    • 1. Circulatory collapse
    • 2. CNS depression
    • 3. Previous hypersensitivity
    • 4. Children
  88. Prochlorperazine (Stemetil) - Side effects
    SHEBS D

    • Drowsiness
    • Blurred vision
    • Hypotension
    • Sinus tachycardia
    • Skin rash
    • Extrapyramidal reactions (usually the dystonic type)
  89. Prochlorperazine (Stemetil) - Special notes
    • IM effect
    • Onset: 20 min
    • Peak: 40 min
    • Duration: 6 hr
  90. Prochlorperazine (Stemetil) - Pharmacology
    • An anti-emetic
    • Action:
    • - Acts on several central neuro-transmitter systems
  91. Salbutamol - Presentation
    • 5 mg in 2.5 mL polyamp
    • 500 mcg in 1 mL glass ampoule
    • 5 mg in 5 mL glass ampoule
    • pMDI (100 mcg per actuation)
  92. Salbutamol - Pharmacology
    • A synthetic beta adrenergic stimulant with primarily beta 2 effects
    • Action:
    • - Causes bronchodilatation
  93. Salbutamol - Metabolism
    By the liver; excreted by the kidneys
  94. Salbutamol - Primary emergency indication
    • 1. Respiratory distress with suspected bronchospasm:
    • - asthma
    • - severe allergic reactions
    • - COPD
    • - smoke inhalation
    • - oleoresin capsicum spray exposure
  95. Salbutamol - Contraindications
    1. IV Salbutamol is no longer indicated for adult Pts
  96. Salbutamol - Precautions
    • 1. Large doses of IV Salbutamol have been reported to cause intracellular metabolic
    • acidosis
  97. Salbutamol - Side effects
    • Sinus tachycardia
    • Muscle tremor (common)
  98. Salbutamol - Special notes
    • IV Salbutamol has no advantage over nebulised Salbutamol provided that adequate
    • ventilation is occurring.
    • Salbutamol nebules / polyamps have a shelf life of one month after the wrapping
    • is opened. The date of opening of the packaging should be recorded and the drug
    • should be stored in an environment of < 30°C
    • Although infrequently used, Salbutamol by IV infusion may be required during
    • interhospital transfers of some women in premature labour
    • The dose is to be prescribed and signed by the referring hospital medical officer
    • Nebulised effects:
    • Onset: 5 – 15 min
    • Peak: n/a
    • Duration: 15 – 50 min
    • IV effects:
    • Onset: 1 – 2 min
    • Peak: n/a
    • Duration: 30 – 60 min

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