Adrenaline (epinephrine) 500 micrograms in 0.5ml (1 in 1000) IM injection in pre-filled autoinjector

Transcription

1 Emergency Medicines Anaphylaxis Adrenaline (epinephrine) 500 micrograms in 0.5ml (1 in 1000) IM injection in pre-filled autoinjector pen (Emerade ) Acute Coronary Syndromes Adrenaline (epinephrine) 1 mg in 10 ml (1 in 10,000) solution for injection in pre-filled syringe Aspirin 300 mg dispersible tablets Glyceryl Trinitrate (GTN) 400 micrograms/metered dose sublingual aerosol spray Status Epilepticus Midazolam Buccal 10mg in 2ml Sugar Free oromucosal solution in prefilled syringe Diazepam 10mg rectal tubes Hypoglycaemia 40% Dextrose in aqueous gel for oral administration (Dextrogel or GlucoGel ) Glucagon 1mg powder and solvent for solution for injection 1mg in 1ml (GlucaGen Hypokit ) Glucose 10% w/v solution for infusion 1

2 Emergency Medicines Overdose OPIOIDS - Naloxone Hydrochloride 400 micrograms/ml solution for injection BENZODIAZEPINE - Flumazenil 0.1 mg/ml solution for injection Reversible airways obstruction Salbutamol 5mg in 2.5ml nebuliser solution Meningococcal disease Benzyl Penicillin Sodium 600mg powder for injection Cefotaxime 1 g powder for injection Dilution Liquids Water for Injections BP Sodium Chloride Injection BP 0.9% w/v Sodium Chloride Intravenous Infusion BP 0.9% w/v 2

3 Anaphylaxis Adrenaline (epinephrine) 500 microgram in 0.5ml Solution for IM injection in pre-filled pen EMERADE Available in bag Administration 2 x auto-injector pre-filled pen May be administered without a prescription for the purpose of saving life in an emergency INTRAMUSCULAR (IM) injection Mid-point of the thigh, anterolateral aspect Injected as slowly as possible & ensure not directly into a blood vessel Further doses can be given at 5-15minutes intervals if the patient s condition dictates (monitor breathing, blood pressure and pulse) Can be injected through clothes Dosage Adult 500 micrograms then repeat after 5-15 minutes as required 3

4 Anaphylaxis Adrenaline 500 microgram in 0.5ml solution for injection Pre-filled auto-injector pen (Emerade ) 4

5 Acute Coronary Syndromes Available in bag Administration Dosage Adrenaline (epinephrine) 1 mg in 10 ml (1:10,000 ten thousand) Solution for injection in pre-filled syringe 3 x Prefilled syringes Intravenous adrenaline should only be administered by those experienced in the use and titration of vasopressors in their normal clinical practice Endotracheal use should only be considered as a last resort if no other route of administration is accessible Only clear colourless solution free from particles or precipitates should be used Do not use if the pouch or the blister has been opened or if the tamper evident seal on the syringe (plastic film at the basis of the end cap) is broken Adult 10 ml of the 1:10,000 (ten thousand) solution (1 mg) by the intravenous or intraosseous route Repeat every 3-5 minutes until return of spontaneous circulation 5

6 Acute Coronary Syndromes Adrenaline 1 mg/10 ml (1:10,000 ten thousand), solution for injection in pre-filled syringe Discard the syringe after use, do not re-use 1) Tear open the aluminium pouch by hand only using the indent(s). Do not use sharp instruments to open the pouch 2) Withdraw the pre-filled syringe from the sterile blister 3) Push on the plunger to free the bung. The sterilisation process may have caused adhesion of the bung to the body of the syringe 4) Twist off the end cap to break the seals. Do not touch the exposed luer connection in order to avoid contamination 5) Check the syringe seal tip has been completely removed. If not, replace the cap and twist again 6) Expel the air by gently pushing the plunger 7) Connect syringe to vascular access device or to needle. Push the plunger to inject the required volume 6

7 Acute Coronary Syndromes Available in bag Administration Aspirin 300 mg Dispersible tablets 32 x 300 mg By mouth: Disperse readily in water or chewed Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to aspirin If aspirin is given before arrival at hospital, send a written record that it has been given with the person Dosage Adult 300mg stat dose: for antithrombotic effect following myocardial infarction, transient ischaemic attack, or in patients with unstable angina 7

8 Acute Coronary Syndromes Available in bag Administration Dosage Glyceryl Trinitrate (GTN) 400 micrograms/metered dose Sublingual aerosol spray 1 x 200 dose aerosol One or two sprays should be administered into the mouth, preferably onto or under the tongue Do not inhale spray The medication should not be expectorated or the mouth rinsed for 5 to 10 minutes following administration A spray may be repeated every 3-5 minutes as needed No more than three metered sprays are recommended within a 15- minute period. If chest pain persists, prompt medical attention is recommended Adult Treatment or prophylaxis of angina, spray 1 2 doses under tongue and then close mouth. Dose may be repeated as required. 8

9 Acute Coronary Syndromes Glyceryl Trinitrate (GTN) 400 micrograms/metered dose Sublingual aerosol spray 1. Remove the plastic cover 2. DO NOT SHAKE 3. Hold the container upright with forefinger on top of the grooved button 4. Open the mouth and bring the container as close to it as possible 5. Press the button firmly with the forefinger to release the spray onto or under the tongue. DO NOT INHALE THE SPRAY 6. Release button and close mouth. Avoid swallowing immediately after administering the spray. The medication should not be expectorated or the mouth rinsed for 5 to 10 minutes following administration 7. If you require a second administration to obtain relief, repeat steps 4, 5, and Replace the plastic cover 9

10 Status Epilepticus Available in bag Midazolam Buccal Liquid 10mg in 2ml Sugar Free 1 x prefilled syringe Administration Oromucosal use The full amount of solution should be inserted slowly into the space between the gum and the cheek (buccal cavity) Approximately half the dose should be given slowly into one side of the mouth, then the other half given slowly into the other side A second or repeat dose when seizures re-occur after an initial response should only be given with prior medical advice Dosage Adult 10mg, then 10mg after 10 minutes if required (unlicensed indication) 10

11 Status Epilepticus Midazolam buccal liquid 10mg in 2ml 1. Hold the plastic tube, break the seal at one end and pull the cap off. Take the syringe out of the tube 2. Pull the red cap off the tip of the syringe and dispose of it safely 3. Using the finger and thumb gently pinch and pull back the child's cheek. Put the tip of the syringe into the back of the space between the inside of the cheek and the lower gum 4. Slowly press the syringe plunger until the plunger stops. The full amount of solution should be inserted slowly into the space between the gum and the cheek (buccal cavity) If necessary (for larger volumes and/or smaller patients), approximately half the dose should be given slowly into one side of the mouth, then the other half given slowly into the other side. 11

12 Status Epilepticus Available in bag Administration Dosage Diazepam 10mg Rectal Tubes 5 tubes To be administered rectally. Adults should be in the lateral position. Tear open the foil pack & remove the cap Insert the tube nozzle completely into the rectum Hold the tube with the spout downwards. The contents of the tube should be completely emptied by using firm pressure with the index finger and thumb To avoid suction, maintain pressure on the tube until it is withdrawn from the rectum. Press the patient's buttocks together for a short time Adult 10-20mg (elderly 10mg), repeat once after minutes if necessary If convulsions are not controlled other anticonvulsive measures should be instituted Elderly and debilitated patients should be given not more than one half the appropriate adult dose Dosage reduction may also be required in patients with liver or kidney dysfunction 12

13 Status Epilepticus (1 of 2) 1. Put the person on their side 2. Get the medicine 3. Get the tube Diazepam 10mg Rectal Tubes 4. Push up with thumb and pull to remove cap from tube. Seal should remove with the cap 5. Lubricate rectal tip with lubricating jelly 6. Turn person on side facing you 7. Bend upper leg forward to expose rectum 8. Separate buttocks to expose rectum 13

14 Status Epilepticus Diazepam 10mg Rectal Tubes (2 of 2) 9. Gently insert tube tip into rectum 10. Slowly count to 3 while gently pushing plunger in until it stops 11. Slowly count to 3 before removing tube from rectum 12. Press the patient s buttocks together for a short time. Camden & Islington NHS Foundation Trust: Emergency medicines: PHA59: April

15 Hypoglycaemia Capillary Blood Glucose (CBG) less than 4 mmol/l Hypoglycaemia is a common complication of glucose lowering therapies, particularly insulin and sulphonylureas (e.g. gliclazide) Elderly patients or those with renal impairment are at particular risk of hypoglycaemia Mild Moderate Severe Patient is conscious, able to swallow and cooperative Dextrose gel 40%: Dextrogel or GlucoGel Patient is conscious, can swallow, but in need of assistance Glucagon injection: GlucaGen Hypokit Patient is unconscious and/or unable to swallow Glucose 10% w/v infusion Always follow up with slowly digested/starchy carbohydrate Check glucose level. Once it is 4 mmol/l or above and patient has recovered, give ONE of the following: 1 slice of bread; half a sandwich; a very small bowl of cereal; a glass of milk with 1 Rich Tea biscuit; or 1 banana Note: Doses of insulin and oral hypoglycaemic medicine will need to be reviewed following an episode of hypoglycaemia. Please contact Diabetes Specialist Nurse or doctor for advice. 15

16 Hypoglycaemia - mild Available in bag Administration Dosage Dextrogel or GlucoGel 40% Dextrose in an aqueous gel 3 x 25g plastic tubes For oral use only. Not to be given to unconscious individuals Twist off cap and squeeze required amount inside the cheek Gently massage the outside of the cheek to aid absorption Alternatively, squeeze required amount into the mouth and swallow Wait 10 minutes, recheck CBG and record. If still below 4 mmol/l or if no physical improvement repeat step 1 Adult 1-2 x 25g tube Dextrogel or Glucogel Repeat after minutes if necessary 16

17 Hypoglycaemia - moderate Available in bag Administration Dosage Glucagon 1mg (GlucaGen Hypokit ) Powder and solvent for solution for injection (1mg in 1ml) 1 x 1mg powder and solvent for solution for injection May be administered without a prescription for the purpose of saving life in an emergency Inject the water for injection (1.1 ml) into the vial containing compacted powder Shake the vial gently until the glucagon is completely dissolved and the solution is clear. Withdraw the solution back into the syringe The reconstituted solution appears clear and colourless and forms an injection of 1 mg (1 unit) per ml Administer by intramuscular injection. The patient will normally respond within 10 minutes Adult 1 mg, if no response within 10 minutes intravenous glucose must be given Glucagon is contraindicated in patients with Phaeochoromocytoma and may be ineffective in chronic hypoglycaemia, starvation, and adrenal insufficiency 17

18 Hypoglycaemia - moderate GlucaGen Hypokit 1mg powder and solvent for solution for injection 1. Push the orange plastic cap off the vial. Pull the needle cover off the syringe and insert the needle through the rubber disc of the vial. Inject all the liquid from the syringe into the vial. 2. Without withdrawing the syringe and needle gently shake the vial until GlucaGen is completely dissolved and the solution is clear 3. Ensure that the plunger is completely depressed. Withdraw all of the solution back into the syringe. Be careful that the plunger is not pulled out of the syringe 4. The solution is used for injection. Ensure there is no air remaining in the syringe before giving the injection. When the patient responds administer oral carbohydrate to prevent a further hypo 18

19 Hypoglycaemia - severe Glucose 10% w/v Solution for Infusion Available in bag Administration Dosage 1 x 500ml Glucose 10% w/v solution for intravenous infusion is a hypertonic solution The osmolarity of a final admixed infusion solution must be taken into account when peripheral administration is considered A gradual increase of flow rate should be considered when starting administration of glucose-containing products Caution irritant & may cause extravasation Adult Give mls 10% w/v Glucose intravenously (if patient has IV access) over minutes 19

20 Overdose - OPIOID Available in bag Administration Dosage Naloxone Hydrochloride 400 micrograms per 1ml solution for injection 10 x 400 micrograms in 1ml ampules May be administered without a prescription for the purpose of saving life in an emergency Naloxone hydrochloride may be administered by intramuscular (IM) or subcutaneous (SC) injection Caution: Lower doses may be required for management of opioid-induced respiratory depression and sedation in those receiving palliative care or chronic opioid use, in particular for pain management. Naloxone has a short duration of action; repeated doses may be necessary to reverse effects of opioids with longer duration of action Adult Initially 400 micrograms, repeat every 2-3 minutes. Further doses may be required if respiratory function deteriorates 20

21 Overdose BENZODIAZEPINE Available in bag Flumazenil 0.1 mg / 1ml solution for injection 5ml ampoules containing 500 micrograms 5 x 5ml ampoules (500 micrograms) Administration Flumazenil must be administered by medical staff only Intravenous (IV) administration Avoid rapid injection in high risk patients Short-acting (repeat doses may be necessary - benzodiazepine effects may persist for at least 24 hours) Caution: prolonged benzodiazepine therapy for epilepsy (risk of convulsions) Caution: head injury (rapid reversal of benzodiazepine sedation may cause convulsions) Dosage Adult (Unlicensed indication) 200 micrograms over 15 seconds, then 100 micrograms at 60-second intervals if required. Usual dose range, micrograms; max. total dose 1 mg 21

22 Reversible airways obstruction Available in bag Administration Dosage Salbutamol 5mg in 2.5ml nebuliser solution 20 x 5mg in 2.5ml ampoules To be administered by a suitable nebuliser, via a face mask or T piece or via an endotracheal tube To be breathed in through the mouth Adult The usual starting dose is 2.5mg as a single dose. This may be increased to 5mg. Salbutamol Nebuliser Solution is designed to be used undiluted. However, if a prolonged delivery time is indicated (more than 10 minutes) then dilution with Sodium Chloride Solution (0.9% w/v) for nebulisation may be required For oxygen driven delivery patients should be given 5mg for 5 minutes with 6 litres of oxygen 22

23 Reversible Airways Obstruction Salbutamol 5mg in 2.5ml nebuliser solution 1. Open the plastic ampoule, take a strip of ampoules from the foil pack 2. Remove one ampoule, replacing the rest back in the foil pack, and replace the foil pack back in the carton 3. Hold the ampoule upright and open it by twisting off the top 4. Squeeze the liquid into the solution holder of the machine or the chamber of the nebuliser mask 23

24 Meningococcal Disease Medicines in the Emergency Drug Cupboard (not in emergency bag) Single dose should be given, if time, whilst waiting for urgent transfer to hospital If possible obtain a blood sample (white blood cell count and lactate) for culture analysis Benzyl penicillin sodium 600mg powder for injection Penicillin allergic Cefotaxime 1g powder for injection Administration Intramuscular (IM) Dissolve in 1.6 to 2.0 ml of Water for Injections BP Reconstituted solutions are for immediate administration Intramuscular (IM) Reconstitute with 4ml of Water for Injections BP Shake well until dissolved Reconstituted solutions are for immediate administration Dosage Adult 1200 mg STAT before transfer to hospital unless history of anaphylaxis (Not just allergy). Adult 1 g STAT before transfer to hospital 24

25 Dilution Liquids in the emergency bag Water for Injections BP Each 1ml of solution contains 1ml of Water for Injections B.P. Available in bag 10 X 10ml ampoules Administration To be used for dilution or reconstitution of certain medicinal products for parenteral administration Not be administered alone, may cause haemolysis Dosage Refer to the instructions for each individual medicinal product for details of volume of diluent and route of administration 25

26 Dilution Liquids in the emergency bag Available in bag Administration Sodium Chloride Injection BP 0.9% w/v Each ml contains 0.9% Sodium Chloride in Water for Injections 5 X 10ml ampoules To be used for dilution or reconstitution of certain medicinal products for parenteral administration Dosage Refer to the instructions for each individual medicinal product for details of volume of diluent and route of administration 26

27 Dilution Liquids in the emergency bag Available in bag Sodium Chloride Intravenous Infusion BP 0.9% w/v 1 x 500ml Administration For intravenous use: Sodium chloride 0.9% intravenous infusion contains Na+ and Cl- each 150 mmol/litre The solution is for administration by intravenous infusion through a sterile and non-pyrogenic administration set using aseptic technique Do not administer unless solution is clear, free from visible particles and the seal intact Dosage Treatment of isotonic extracellular dehydration and sodium depletion: 500 ml to 3 litres / 24 hours Recommended dosage when used as a vehicle or diluent ranges from 50 to 250 ml per dose of medicinal product to be administered Treatment for Sepsis: With a bolus of 500ml over less then 15 minutes 27

28 References ANAPHYLAXIS: 1. C&I Foundation Trust Anaphylaxis Guidelines May Resuscitation Council (UK) Emergency treatment of anaphylactic reactions: Guidelines for healthcare providers. January 2008 (annotated with links to NICE guidance in July 2012) 3. NICE clinical guidance (CG 134): Anaphylaxis: assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode. Available at: (Accessed: 10/05/2016) 4. EMC (2016) Emerade, 500 micrograms, solution for injection in pre-filled pen, Available at: (Accessed: December 2016). 5. BNF - Medicines Complete (2016) ADRENALINE/EPINEPHRINE, Available at (Accessed: December 2016) CARDIAC ARREST 1. BNF On line, Medical emergencies in the community, Available at: medical-emergencies-in-the-community.htm?q=soluble%20aspirin&t=search&ss=text&tot=8&p=6#_hit (Accessed: 02/11/2016). 2. Handbook of Drug Administration via Enteral Feeding Tubes, Dispersible aspirin, Available at : (Accessed: 2/11/2016) 3. Thomas & Guy Foundation Trust - Using your GTN spray to treat your chest pain, Leaflet number: 2484/VER3 Date published: February Guy s and St Thomas NHS Foundation Trust. Available at: (Accessed: 2/11/2016). 4. Drugs Data Base NITROLINGUAL - nitro-glycerine spray, metered Physicians Total Care, Inc. Available at (Accessed on 2/11/206). 28

29 References CARDIAC ARREST 1. BNF (Medicines Complete) (2016) Aspirin, Available at: (Accessed: May 2016). 2. EMC (2015) Boots Aspirin 300mg Dispersible Tablets, Available at: (Accessed: May 2016). 3. EMC (2016) Adrenaline 1 mg/10 ml (1:10,000), solution for injection in pre-filled syringe, Available at: (Accessed: May 2016). STATUS EPILEPTICUS 1. Holsti M, Dudley N, Schunk J, Adelgais K, Greenberg R, Olsen C, Healy A, Firth S, & Filloux F (2010). Intranasal midazolam vs rectal diazepam for the home treatment of acute seizures in paediatric patients with epilepsy. Archives of paediatrics & adolescent medicine, 164 (8), PMID: Wong L, McQueen KD. Midazolam routes of administration. DICP Ann Pharmacother 1991; 25: PubMed 3. EMC (2016) BUCCOLAM 2.5mg, 5mg, 7.5mg and 10 mg oromucosal solution,available at: (Accessed: October 2016). 4. BNF - Medicines Complete (2016) DIAZEPAM, Available at (Accessed: August 2016) 5. EMC (2015) Diazemuls, Available at: (Accessed: August 2016). EMC (2015) Diazepam RecTubes 10mg, Available at (Accessed: August 2016). 6. Orange County EMS (2016) Rectal Administration of Diazepam Gel, Available at (Accessed: September 2016). 29

30 References HYPOGLICAEMIA 1. Baldwin E.J, Feher, M.D Sweets, fluids and food in the treatment of mild hypoglycaemia. Practical diabetes international 2006, Vol 23, N 5, p Diabetes UK (2016) HYPOS AND HYPERS, Available at: (Accessed: November 2016). 3. BNF (Medicines Complete) (2016) GLUCAGON, Available at: (Accessed: October 2016). 4. Dr M.Barnard, E. Baker - Whittington Trust Hospital (2013) Hypoglycaemia Management for Adult Inpatients with Diabetes, Available at: s a (Accessed: September 2016). 5. EMC - SPC (2015) GlucaGen Hypokit 1 mg, Available at: (Accessed: September 2016). 6. Medicines Complete (2016) Treatment of hypoglycaemia, Available at: (Accessed: November 2016). 7. NeoCeuticals Dextrogel - Fast Acting Dextrose Gel, Available at: (Accessed: September 2016). 8. Novo Nordisk Pharmaceuticals Ltd. (2015) GlucaGen KIT 1 mg, Available at: (Accessed: May 2016). NALOXONE & FLUMAZENIL 1. BNF (Medicines Complete) (2017) FLUMAZENIL, Available at: (Accessed: April 2017). 2. EMC (2012) Flumazenil 0.1 mg/ml solution for injection, Available at: (Accessed: May 2016). 3. Flumazenil Martindale (Medicines Complete (2016), available on line at: (Accessed October 2016) 4. International Medication Systems, Limited (2015) Naloxone hydrochloride injection, Available at : (Accessed: May 2016). 5. NICE Clinical guideline [CG16] (2004) Self-harm in over 8s: short-term management and prevention of recurrence, Available at: (Accessed: May 2016). 30

31 References REVERSIBLE AIRWAYS OBSTRUCTION 1. EMC (2016), Ventolin Nebules 2.5mg, 5mg Available at: (Accessed: December 2016). 2. BNF (Medicines Complete) (2016), SALBUTAMOL Available at: (Accessed: December 2016). MENINGOCOCCAL DISEASE 1. EMC (2016),Cefotaxime Powder for solution for injection or infusion Available at: (Accessed: December 2016). 2. BNF (Medicines Complete) (2016) CEFOTAXIME, Available at: (Accessed: December 2016). 3. EMC (2016), Benzyl penicillin sodium 600mg Powder for Injection Available at: (Accessed: December 2016). 4. BNF (Medicines Complete) (2016) BENZYLPENICILLIN SODIUM(Penicillin G), Available at: (Accessed: December 2016). 5. C&I Foundation Trust Antimicrobial Guidelines available on Trust Intranet. DILUTION LIQUIDS 1. EMC (2015) Sterile water for injection, Available at: (Accessed: August 2016). 2. EMC (2016) Sodium Chloride Intravenous Infusion BP 0.9% w/v, Available at: (Accessed: August 2016). 3. BNF (Medicines Complete) (2016), SODIUM CHLORIDE Available at: (Accessed: December 2016). 4. National Institute for Health and Care Excellence (July 2016) Sepsis: recognition, assessment and early management (NG51) available at: nice.org.uk/guidance/ng51 LEGAL REQUIREMENTS 1. Human Medicines Regulations 2012 SCHEDULE 19 Medicinal products for parenteral administration in an emergency. Available at (Accessed: December 2016) 2. Resuscitation Council UK (2016), Mental health - Inpatient care - equipment and drug lists, Available at (Accessed December 2016) 31