Mountain Rescue England and Wales DRUG FORMULARY

Transcription

1 Mountain Rescue England and Wales DRUG FORMULARY Intended for the use of team members with a current Casualty Care Certificate during the period June 2014 to May Introduction Introduced in 1991 this is the sixth revision of the Mountain Rescue England and Wales (MREW) Formulary (Drug List). It incorporates the changes in the Medicines Act (2006) and Controlled Drug License (2007) as well as experience gained in mountain rescue and pre-hospital care. A new Controlled Drug License will be issued in 2014 and yearly compliance visits by the Home Office will take place across MREW Regions. The reasons for having a restricted list are unchanged: a. It is good clinical practice to work from a limited formulary and thus acquire greater familiarity and confidence with these drugs. b. The use of a limited formulary is now standard in medical practice. c. Teaching is much simpler and allows standard examination questions. Drug names in BOLD CAPITALS will be tested in the Casualty Care exam. Although these are not all generic names they have been retained to avoid confusion because they have been accepted within MR. d. Progressing knowledge about the effective use of drugs in a mountain rescue (MR) can only be achieved by pooling information using the same medications. e. Provision of medico-legal insurance is easier if we are able to define clearly what we are doing. There is however some flexibility as a consequence of the MR amendment to the Medicines Act. This allows medically qualified doctors to vary the team s drugs where appropriate. The principal considerations when selecting drugs have been as follows: i. As few a number of drugs as possible to cover needs. ii. Effective, quick acting, easy to administer, and minimal side effects. iii. A long shelf life and an acceptable cost. General Notes Teams and individuals should carry the minimum quantities to meet anticipated needs. Familiarity with techniques of delivery is vital. This is especially so with inhalers and injections. Where a choice exists, use the simpler mode of delivery - do not use an injection if oral drugs will suffice. Children refers to persons under the age of 12 years unless otherwise specified. Records and Audit trail Medications must checked by two people, preferably another team member with the Casualty Care Certificate, check the proposed drug, its indication and absence of contraindications. The recording of drugs given is mandatory both on the MR Casualty Card and the MREW incident report. To administer a drug and not make a written record is inexcusable clinical practice. The record should include: the name of the drug, the dose, the route, time of administration, and the name of the carer who MREW Medical Subcommittee. Drug Formulary May Review date May 2017.

2 administered the medication, and should be transferred at handover. If any adverse drug reaction or incident occurs, it should be recorded on the MR Casualty Card and reported as an Incident Report Form to the MRC Medical Officer using the form on the MREW website. This is a non-judgmental process essential to the safe practice of the use of medicines. It is for the benefit of the casualties, careers and organizations, shares learning and informs future practice. In respect to controlled drugs, teams and individuals must comply with the legislation and regulations of the Misuse of Drugs Acts and implement all aspects of good practice in the handling, storage and administration of these drugs. Your must maintain a traceable written record of such all medicines which must be copied to the MREW Medical Officer for January 1 each year. You must keep your Controlled Drug registers for a minimum of 7 years. Each team should have a Standing Operating Procedure for the handling, storage and administration of controlled drugs. MREW Medical Subcommittee. Drug Formulary May Review date May

3 The drugs are arranged in three sections as follows: Group 1 Group 2 Group 3 Drugs to be carried by individual team members. Drugs to be carried by teams. Drugs for use by Doctors and other suitable persons. These Groups were originally envisaged as physical entities or kits. It may however be more appropriate to think of Groups referring to who might carry and administer the drug. Drugs in Group 1 and 2 are suitable for a Casualty Career whereas drugs in Group 3 require further training, additional skills and a more critical appraisal of the benefits of administering the drug over the risks involved in a remote setting. The MREW does not detail the use of Group 3 drugs; non-doctors using Group 3 drugs will have been trained by a doctor who is also responsible for assessment of competency. They will supply appropriate drugs and monitor their trainee. In contrast to pre-2006, the doctor is not exposing himself to criminal proceedings, nor if he supplies a drug from Group 3 to negligence claims, because the MREW have appropriate liability insurance. However he/she is responsible for appropriate training and adequate supervision of the trainee. ORAL GLUCOSE (e.g. GLUCOGEL ) ASPIRIN PARACETAMOL IBUROFEN FORMULARY SUMMARY (DRUG LISTS) Group 1 (Individual) OXYGEN Group 2 (Team) OXYGEN 50%/NITROUS OXIDE 50% (ENTONOX, NITRONOX ) MORPHINE NALOXONE PROCHLORPERAZINE (BUCCASTEM ) GLYCERYL TRINITRATE SPRAY CEFUROXIME SALBUTAMOL IPRATROPIUM EPINEPHRINE (ADRENALINE) MIDAZOLAM (Intranasal or Buccal) MREW Medical Subcommittee. Drug Formulary May Review date May

4 Group 3 (Optional. Suitably Qualified Practitioners) Group 3 is regarded as optional; some teams without medical or paramedic support, or sufficient rescue activity, may feel its use would so infrequent that the expense and training cannot be justified. The contents will depend on the preference of the team, their medical input well as the skills and training of the rescuers. For the benefit of a suitable team, a list of suggested drugs is included. Some uniformity at least in the classes of drugs carried is desirable. s and doses are not given for all medications as medical supervision is assumed. Advisory sheets are included for TRAMEXAMIC ACID and INTRA NASAL DIAMORPHINE. Tramexamic acid has a recognized place in the management of hemorrhage associated with trauma. Intranasal Diamorphine has a well-established safety profile and an increasing use across MR teams. If a team is considering using other drugs, they may wish to discuss the matter with the MRC Medical Officer. Suggested Drugs: ANTIBIOTIC INJECTION (e.g. CEFUROXIME) ANTIEMETIC INJECTION (e.g. METOCLOPAMIDE, ONDANSTERON) BENZODIAZEPINE INJECTION OR BUCCAL (e.g. LORAZEPAM, MIDAZOLAM); CHLORPHENAMINE INJECTION GLUCAGON INJECTION HYDROCORTISONE INJECTION INTRA NASAL DIAMORPHINE FENTANYL LOZENGES KETAMINE LOCAL ANAESTHESIA (e.g. LIGNOCAINE) TRAMEXAMIC ACID. Summary of Major Changes for 2014 edition. Ibuprofen replaces Diclofenac in Group 1. Expanded guidance on use of Oxygen Group 2. The use of buccal or intranasal midazolam replaces PR Diazepam in Group 2. Recommendation for inclusion of Intranasal Diamorphine Group 3 with guidance notes. Recommendation for inclusion of Tramexamic acid in Group 3 with guidance notes. MREW Medical Subcommittee. Drug Formulary May Review date May

5 Group 1 Individual Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with exceptions amendment to Medicines Act 2006) ASPIRIN Action if patient declines or is excluded / comments Patient who are believed to have suffered myocardial infarction (Heart Attack) or frostbite Adults A definite history of allergy (usually in the form of breathing problems and or skin rash) to aspirin of other anti-inflammatory medicine (NSAID) e.g. Ibuprofen. Patient already taking anticoagulant e.g. warfarin. Stroke Children under 16 years Already taken a 300 mg tablet today. Patients taking drugs with a name ending in pril for heart failure Unless there is a clear history of allergy the benefit of a single low dose in this situation outweigh the disadvantages. Name form & strength of medicine Casualty Carer Tablet containing 300 mg. Oral preferably soluble or chewable form. 300 mg. Once. 300 mg. Allergy. Gastrointestinal bleeding risk from a single dose is very low and can be ignored in this indication. Current MREW Casualty Care Certificate. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List MREW Medical Subcommittee. Drug Formulary May Review date May

6 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with exceptions amendment to Medicines Act 2006) PARACETAMOL The relief of mild to moderate pain such as minor injury or headache. As part of a combined analgesic strategy in severe pain. Adults and children 6 years and over. A known paracetamol allergy. Recent dose of paracetamol within last 4 hours. Name form & strength of medicine Casualty Carer Tablet containing 500 mg. Oral. Adult: 2 X 500 mg tablets. Child years: mg (one or one and a half x 500mg tablets) Child 10 to 12 years 500 mg (One 500 mg tablet). Child:6 to 9 years 250 mg (Half 500mg tablet) 4-6 hours. Adult: 4 grams in 24 hours. Child 10 or 11 years: 2 grams in 24 hours. Child 6 to 9 years: 1 gram in 24 hours. None in acute situation. Current MREW Casualty Care Certificate. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List 2010 MREW Medical Subcommittee. Drug Formulary May Review date May

7 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with exceptions amendment to Medicines Act 2006) IBUPROFEN Mild to moderate pain. e.g. Sprained ankle. Severe pain when used as part of a combination analgesic strategy. Adults and Children 7 years and over. Known allergy to anti-inflammatory medicines, including aspirin. Shocked trauma patients. Known kidney disease. Severe dehydration. Regular indigestion or history of bleeding from an ulcer in the gut. Pregnancy. Asthma possible hypersensitivity and wheezing most asthmatics will know if they can take NSAIDs. Patients over 65 years with history of intolerance to NSAIDs or have ischaemic heart disease of renal (kidney) disease. Name form & strength of medicine Casualty Carer Tablet containing 200 mg or 400 mg. Oral. Adults: 400 mg. Child 7 to 12 years 200 mg. Three times daily 8 hourly. Adult: 2.4 grams in 24 hours. Child 7 to 12 years 600 mg in 24 hours. Nausea. Vomiting. Bleeding into gut. Rare in single does in acute situation. Current MREW Casualty Care Certificate Can be used in addition to paracetamol. Both drugs to be given in full dose they work in different ways and work synergistically. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List MREW Medical Subcommittee. Drug Formulary May Review date May

8 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) ORAL GLUCOSE (e.g. Glucogel) Action if patient declines or is excluded / comments Hypoglycaemia (low blood sugar) complicating diabetes mellitus. Exhaustion hypothermia. Adults and children. None. Advice should be sought for a diabetic who fails to respond to oral glucose. In these cases consider IM glucagon. In hypoglycaemia the urgency in giving glucose cannot be overstated. If in doubt about the diagnosis in an unconscious patient give glucose. You will do no harm if the blood sugar is already high. Name form & strength of medicine Oral glucose gel. A variety of gels are available. Oral. It can be rubbed on gums and inside of cheek and will be absorbed if the patient is unconscious. In the unconscious patient, be careful to ensure that the fluid is not inhaled grams. (Approx 2 teaspoons of sugar) Repeated as required. Guide every 5 minutes. No limit. None. Casualty Carer Current MREW Casualty Care Certificate. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List 2010 MREW Medical Subcommittee. Drug Formulary May Review date May

9 Group 2 Team Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) PROCHLORPERAZINE (BUCCASTEM) Nausea and vomiting from any cause. Adults. Children. Elderly (can cause dystonia- abnormal muscle spasm). Name form & strength of medicine Casualty Carer Tablet containing 3 mg. Placed between gum and cheek. Buccal. 2 X 3 mg tablets. 2 tablets (6 mg). Dystonia (abnormal muscle spasm) see above. Rarely respiratory depression. Current MREW Casualty Care Certificate. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List MREW Medical Subcommittee. Drug Formulary May Review date May

10 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) CEFUROXIME Major contaminated wound with or without fracture. Open fracture. Adults and children 5 years and older. History of allergy to Penicillin or Cephalosporin antibiotics. Ask for medical if allergy is uncertain. Name form & strength of medicine Tablets containing 250 mg. Intravenous dose 1500 mg. Oral tablet do not crush IV trained individuals. (To 1.5 g powder for solution add Water for Injection making up to at least 15mL.) Adult 2 x 250 mg tablets. Child > 5 years 1 x 250 mg tablets Adult & children over 40kg (approx. 12 yrs.) 1500 mg IV. Casualty Carer Once. Adult Oral 1 gm. Child > 5 years 250 mg orally Adult IV 1.5 gm. Allergic reaction. Oral administration - Current MREW Casualty Care Certificate. Ability to manage anaphylactic reaction. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC BNF V MREW Drug List 2010 MREW Medical Subcommittee. Drug Formulary May Review date May

11 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) OXYGEN 50% with NITROUS OXIDE 50% (ENTONOX R, NITRONOX R ) Mild to moderate pain. Adults and children. Patient is unable to hold mask and self-administer treatment. Head injury with decreased level of consciousness Possible pneumothorax. History of diving in past 24 hours. This gas mixture separates in low temperatures minus 6 degrees C. The cylinder should be stored in warm environment. In a cold environment the cylinder MUST be inverted several times to mix gases in low temperatures. Inversion whilst the cylinder is still cold does not work. Consider another choice of analgesia in low temperatures. Name form & strength of medicine Casualty Carer Gas supplied in pressurised cylinder (blue) with regulator valve. Self-administered through mask or mouth piece. May take 3-5 minutes to reach maximum effect. Inhalation with each breath. Normal breathing is sufficient. Do not encourage hyperventilation. As required. Duration of treatment Dizziness, euphoria, nausea. Current MREW Casualty Care Certificate. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List 2010 MREW Medical Subcommittee. Drug Formulary May Review date May

12 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) EPINEPHRINE (Adrenaline) Referral arrangements Life threatening allergic reaction. Life threatening asthma with imminent respiratory failure. Cardiorespiratory arrest with asthma. Cardiac arrest (as part of Advanced Life Support). Do not use in cardiac arrest in hypothermic patients. EPINEPHRINE is used in life threatening situation and all patients must be transferred to hospital as emergency cases. Name form & strength of medicine Ampoule containing 1 mg of 1:1000. Prefilled EPIPEN 0.3mg, ANAPEN 300 or JEXT 300micrograms pen IM injection anterolateral aspect of thigh or outer aspect of upper arm. IV injection, followed by 20mL sodium chloride for injection Intraosseous injection Life threatening Allergy or Asthma: IM injection: Adult and child over 12yrs: 500micrograms (0.5mL) Child 6-12 yrs 300 microgrmas (0.3mL) Prefilled Autoinjector Adult and child over 6 years 300micrograms. Cardiac Arrest: 1 mg IV /IO flush IV with saline. 5 min. Two doses and then seek medical. MREW Medical Subcommittee. Drug Formulary May Review date May

13 Casualty Carer Anxiety and tremor. Current MREW Casualty Care Certificate UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List UK Resuscitation Guidelines MREW Medical Subcommittee. Drug Formulary May Review date May

14 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) GLYCERYL TRINITRATE SPRAY Referral arrangements Chest Pain due to angina or myocardial infarction. Adults with cardiac chest pain. Children. Clinically shocked or measured blood pressure systolic < 100 mg Hg. All patients with cardiac chest pain should be referred to hospital for assessment. Name form & strength of medicine Metered dose spray 400 micrograms per dose. Spray under patient s tongue. 1-2 sprays under tongue. ( micrograms). Repeated 5-10 minutes according to effect maximum 2 doses. Two doses and then seek medical. Headache, flushing. Low blood pressure. May make hypothermia worse (keep warm). Casualty Carer Current MREW Casualty Care Certificate UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List MREW Medical Subcommittee. Drug Formulary May Review date May

15 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) IPRATROPIUM BROMIDE Referral arrangements Asthma. Acute severe asthma attack. (Unable to speak in complete sentences, pulse > 110 bpm, respiratory rate > 25 bpm, oxygen saturation < 96% in air). None in an emergency situation. None in emergency situation. All patients with severe asthma should receive a medical assessment. Name form & strength of medicine Nebules containing 250 micrograms in 1 ml or 500 micrograms in 2 mls. Nebulised through oxygen at 6 8 l / minute. Can be given simultaneously with salbutamol by nebuliser. Adult: 2 X 250 micrograms. Child: 1 X 250 micrograms. Once. Then seek medical. Adult: 500 micrograms. Casualty Carer Child: 250 micrograms. Headache, nausea, dry mouth, fast heart rate. Current MREW Casualty Care Certificate UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List 2010 MREW Medical Subcommittee. Drug Formulary May Review date May

16 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) MIDAZOLAM (Intranasal) Caution / Need for further Referral arrangements Epileptic fit. Adults and children. Do not use in fits due to head injury. Seek for prolong fits when possible. Any patient a new onset fit must be referred for medical assessment. For a recurrent fit in a known epileptic with full recovery advise the patient to seek follow up. Name form & strength of medicine Casualty Carer Hypnovel solution 5 mg /ml. Either Buccolam or Midazolam injection solution may be used. Intranasal via atomiser. 5mg in each nostril. Oromucosal administration. Adult:10 mg Child: 5-12 years 5 mg. Repeat at 10 min if fit continues then seek medical. Twice and then seek. Respiratory depression. (Give oxygen support ventilation.) Current MREW Casualty Care Certificate. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List MREW Medical Subcommittee. Drug Formulary May Review date May

17 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with exceptions amendment to Medicines Act 2006) MORPHINE Relief of moderate or severe pain. In mountain rescue the most likely to be due to limb fractures or heart attack. Administration should be in conjunction with a pain score which should then be used to monitor the effect. Respiratory depression (adult < 10 breaths per minute child, 20 breaths per minute, oxygen saturation < 94 %). Clinical signs of shock (or actual measured systolic blood pressure < 90 mmhg in adults or, 80 mm hg in school children). Head injury with GCS equal or less than 10. Below P on AVPU scale. Known hypersensitivity to morphine. Pregnancy, Chest injury if breathing is inhibited by pain the use of carefully titrated analgesia will improve oxygenation and ventilation. Head Injury the decision to administer opiate analgesia to a patient with potential brain injury is a clinical decision. The beneficial effects of pain relief, improved oxygenation and ventilation in some patients must be weighed against the potential for hypotension and hypoventilation. When in doubt ask for before administration in the above conditions and monitor patient carefully. Name form & strength of medicine Ampoules containing 10 mg in 1 ml. IM MREW Casualty Carers. IV Trained individuals. Adult: mg IM injection. Child: 7-12 years 2.5 mg IM. 5-7 years 2 mg IM. IV Adult 5 mg and titrate to response. Titrated to response. 15 mg then seek medical. Nausea and vomiting. Drowsiness. MREW Medical Subcommittee. Drug Formulary May Review date May

18 Casualty Carer Respiratory depression and hypotension. Pupil constriction. Current MREW Casualty Care Certificate. Ability to administer Naloxone. Records / audit trail Morphine is a class A (Schedule 2) controlled drug and must be stored and prescribed and administered in accordance with these regulations. The drugs should be checked by two carers and the Team s controlled drugs register witnessed countered signed as required. Unused morphine must be discarded in the presence of a witness. All medicines to be recorded on casualty record card with name of carer who administered the medication and to be transferred at handover. Medicines to be recorded in MREW database. Any adverse events to be notified using MREW incident report to MREW Medical Officer. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List 2010 Ellerton et al. The use of analgesia in mountain rescue casualties with moderate or severe pain. EMJ. 2013;30, MREW Medical Subcommittee. Drug Formulary May Review date May

19 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) NALOXONE To reverse the effects of opiate e.g. morphine, diamorphine heroin, codeine etc. 1.When in treating pain a Casualty Carer accidently gives too much morphine. 2. When a casualty accidently or intentionally takes an overdose of drugs such as heroin or codeine. The effect of NALOXONE is to reverse the severe side effects such as respiratory, cardiac and nervous system depression. It should be administered if the respiratory rate < 10 breaths per minute, the patient cannot maintain their airway, or the patient is unconscious GCS <10, AVPU <P. N.B. It also reverses all the analgesia. Action if patient declines or is excluded / comments Referral arrangements None. Failure to respond return of complication despite repeated doses of NALOXONE. All patients who have taken an accidental or intentional overdose should be transferred to hospital for assessment. Name form & strength of medicine Ampoule containing 400 micrograms in 1 ml. IM, IV, IN. IM = 400 micrograms. IV = 400 micrograms. IN =2 mg 1 mg each nostril via atomizer. Children 10 mcg/kg body weight. NB NALOXONE has a very short duration of action (half-life). Repeat doses at 3 min intervals. 4 doses and then seek medical Return of pain, cardiac arrhythmias including cardiac arrest, shortness of breath and acute withdrawal in drug addicts MREW Medical Subcommittee. Drug Formulary May Review date May

20 Casualty Carer Current MREW Casualty Care Certificate Airway management. Breathing support mouth to mask or Bag-valve-mask. Delivery of supplementary oxygen. These should started immediately while NALOXONE is prepared. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List MREW Medical Subcommittee. Drug Formulary May Review date May

21 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with exceptions amendment to Medicines Act 2006) OXYGEN All seriously injured or ill patients and those with abnormal vital signs or a reduced conscious level. Adults and Children Conditions which do not require routine oxygen unless the patient has an oxygen saturation below 94% (measured with pulse oximetry with good signal): Heart attack and chest pain. Stroke. Heat exhaustion. However if in doubt it is safe to administer oxygen to these conditions. Patients with severe COPD (Chronic Obstructive Pulmonary Disease) require careful monitoring of oxygen therapy. These patients are very rare in the practice of casualty care on the mountains. Safety considerations in enclosed environments e.g. tents where there maybe flames or sources of ignition. Name form & strength of medicine Gas provided in pressurised cylinder with flow regulating valve. Black / white cylinder Inhaled through mask. A non- rebreathing oxygen mask with an initial flow rate of l/min should be used. (Use a lower flow if supplies are limited) If oxygen is used to drive a nebuliser for asthma treatment flow rate 4-8 l / min l / min until vital signs are normal and then deliver enough oxygen to maintain a saturation of 94-98% (measured with pulse oximeter with good signal). Continuous flow. As required. None in acute situation. MREW Medical Subcommittee. Drug Formulary May Review date May

22 Casualty Carer Current MREW Casualty Care Certificate. UK SAR Medical Group Oxygen Guidelines. British Thoracic Oxygen Treatment Guidelines UK Ambulance Service Clinical Practice Guideline 2013.JRCALC. BNF V MREW Medical Subcommittee. Drug Formulary May Review date May

23 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) SALBUTAMOL Adult or child with acute asthma attack. None in acute asthma. Referral arrangements Patients with severe episode should have medical assessment. Name form & strength of medicine Pressurized multidose inhaler Nebules 2.5 mg in 2.5 mls. Deliver via spacer device. Delivery via oxygen driven nebuliser if available. Can be given with Ipratropium. Adult: 2-10 puffs via spacer. Adult: Nebulised 2 X 2.5 mg in 5ml solution. Child: 2-6 puffs in spacer. Child: Nebulised 2.5 mg in 2.5 mls minutes. Repeat twice and then seek medical. Casualty Carer Asthma where patient was forgotten medicines or asthma has failed to respond to normal treatment. Tremor, fast pulse, headache. Current MREW Casualty Care Certificate BNF V MREW Drug List 2010 MREW Medical Subcommittee. Drug Formulary May Review date May

24 Group 3 Optional. Suitably Qualified Practioners Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) Guideline provided as for Suitably Qualified and Trained Carer. TRAMEXAMIC ACID Trauma patients with time critical injury where internal or external bleeding is suspected. Consider in the following: A trauma patient with clinical signs of shock or measured altered physiology. Isolated head injury If critical intervention leave insufficient time for administration in the field. Bleeding has now stopped. Injury time > 6 hours. Name form & strength of medicine Casualty Carer Records / audit trail Ampoule containing 500 mg in 5 ml. IV slowly over 10 minutes. Adults:1 gm. Once only. 1 gm. Rapid injection can cause hypotension. Suitably qualified and trained carer. All medicines to be recorded on casualty record card with name of carer who administered the medication and to be transferred at handover. Medicines to be recorded in MREW database. Any adverse events to be notified using MREW incident report to MREW medical Officer. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. CRASH 2 Shakur H et al.lancet.2010.jul; 3; 376(9734): MREW Medical Subcommittee. Drug Formulary May Review date May

25 Notes CRASH 2 trial demonstrated that this treatment is safe and effective with 9% reduction in deaths. No evidence about benefit in isolated head injury but no evidence of harm. MREW Medical Subcommittee. Drug Formulary May Review date May

26 Mountain Rescue England and Wales Patient Group Directive (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) Guideline provided as for Suitably Qualified and Trained Carer. DIAMORHINE (Intranasal Route) Relief of moderate and severe pain. In mountain rescue this is most likely to be due to trauma such as limb fractures or heart attack. Administration should be in conjunction with a pain score which should then be used to monitor the effect. Known allergy to diamorphine or morphine. Injury to nose or bleeding from nose. Respiratory depression (adult < 10 breaths per minute child, 20 breaths per minute, oxygen saturation < 94 % without medical ) Clinical signs of shock. (or actual measured systolic blood pressure < 90 mmhg in adults or, 80 mm hg in school children) Head injury with GCS equal or less than 10. Below P on AVPU scale. Pregnancy. Chest injury if breathing is inhibited by pain the use of carefully titrated analgesia will improve oxygenation and ventilation. Head Injury the decision to administer opiate analgesia to a patient with potential brain injury is a clinical decision. The beneficial effects of pain relief, improved oxygenation and ventilation in some patients must be weighed against the potential for decreasing blood pressure and decreasing ventilation and oxygenation. When in doubt ask for medical before administration in the above conditions and monitor patient carefully. Name form & strength of medicine DIAMORPHINE Ampoule containing 5 mg or 10 mg powder. Intranasal. 5 mg. Reassess at 15 min with pain score titrate as required and observe for side effects. 15 mg then request medical. Drowsiness, respiratory depression, MREW Medical Subcommittee. Drug Formulary May Review date May

27 Casualty Carer hypotension. Current MREW Casualty Care Certificate. The competencies to manage side effects. The ability to use Naloxone. Additional training and testing of competency is required at local level to implement this PGD. Records / audit trail Diamorphine is a class A (Schedule 2) controlled drug and must be stored and prescribed and administered in accordance with these regulations. The drugs should be checked by two carers and the Team s controlled drugs register witnessed countered signed as required. Unused diamorphine must be discarded in the presence of a witness. All medicines to be recorded on casualty record card with name of carer who administered the medication and to be transferred at handover. Medicines to be recorded in MREW database. Any adverse events to be notified using MREW incident report to MREW Medical Officer. UK Ambulance Services Clinical Practice Guidelines 2013 JRCALC. BNF V MREW Drug List Guideline Intranasal Diamorphine MREW Website. Ellerton et al. The use of analgesia in mountain rescue casualties with moderate or severe pain. EMJ. 2013;30, MREW Medical Subcommittee. Drug Formulary May Review date May

28 Patient Group Directives for Medications used by Mountain Rescue England and Wales. (Non NHS Delivery of medicines in accordance with amendment to Medicines Act 2006) Responsible Officer: M.K Greene. MREW Medical Officer. Reviewed MSC Clinical Practice Working Group March Reviewed and Agreed by MREW Medical Subcommittee May Review date: May Name Designation Signature Date M Greene Chair MREW Medical Sub Mike Greene 17/6/14 Committee K Ball Clinical Pharmacist North Cumbria University Hospital Trust. K Ball 17/6/14 MREW Medical Subcommittee. Drug Formulary May Review date May