Medicines Included in Deteriorating Patients medicine Box (RED):

Quick Reference Guide for: Deteriorating Patients Medicines Box (RED) Please Note: Any medicines given must form part of an Airway, Breathing, Circulation, Disability and Exposure (ABCDE) Assessment (9)999 must be telephoned, followed by doctor on call The administration of Medicines must NOT delay (9)999 or transfer to definitive care Medicines Included in Deteriorating Patients medicine Box (RED): Medicine Page Adrenaline 1mg/1mL (1:1,000) Injection Ampoule for Anaphylaxis 3 Chlorphenamine 10mg/1mL Injection Ampoule 5 Hydrocortisone 100mg/1mL Injection Ampoule 7 Salbutamol 5mg/2.5mL Nebuliser Ampoule 9 Ipratroprium Bromide 500microgram/2 ml Nebuliser Ampoule 11 Aspirin 300mg Tablet 13 Glyceryl Trinitrate (GTN) 400microgram Spray 15 Glucagon 1mg/1mL (Powder and Diluent) Injection 17 Naloxone 400microgram/1mL Injection Ampoule 19 Midazolam 10mg / 1mL Buccal Liquid 21 Flumazenil 500micrograms/5mL Injection Ampoule 23 Furosemide 50mg/5mL Injection Ampoule 25 Further information can be gained from National Poisons Information Service (www.toxbase.org) Phone No 0344 892 0111. This service is only available to NHS professionals, and is staffed 24-hours a day, 365 days a year. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 1 of 26

Medicines that can be administered IN AN EMERGENCY without a prescription by a competent clinician.* Medicines that must be administered against a PRESCRIPTION, Patient Group Direction (PGD) or Protocol by a competent clinician. For administration by a Doctor, who in their professional opinion is competent to use it safely. *Reference: The Human Medicines Regulations 2012- Schedule 19 Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 2 of 26

Adrenaline 1mg/1mL (1:1,000) Injection Ampoule for Anaphylaxis Indications: First line treatment for acute anaphylaxis Adult Dose: 0.5mg (500micrograms)/0.5mL. Further doses can be given at 5 minute intervals if there is no improvement in the patient s condition see algorithm overleaf Instruction for Dilution: None required Route: IM (Intramuscular) Instruction for Administration: 0.5mg/0.5mL to be administered IM into the upper outer thigh. IM injections of adrenaline into the buttocks should be avoided because of the risk of tissue necrosis Protocol: Can be administered in an emergency without a prescription Caution: Diabetes mellitus, hypertension and hyperthyroidism. Adrenaline must NOT be given intravenously for treating anaphylaxis within Oxford Health NHS Foundation Trust Side Effects: Anxiety, tremor, tachycardia, arrhythmias, cold extremities, hypertension, nausea, vomiting, sweating, weakness, dizziness Contraindications: Adrenaline is contraindicated in patients with shock (other than anaphylactic shock), narrow angle glaucoma, organic heart disease or cardiac dilatation Adrenaline must NOT be given intravenously for treating anaphylaxis within Oxford Health NHS Foundation Trust Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 3 of 26

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Chlorphenamine 10mg/1mL Injection Indications: Emergency (second-line) treatment of anaphylactic reaction. See protocol overleaf Adult Dose: Chlorphenamine 10mg (1mL) Instruction for Dilution: None required Route: IM (Intramuscular) or IV (Intravenous) Instruction for Administration: Via IM injection. Alternatively it may be given to adults by slow IV injection over 1 minute Protocol: Can be administered in an emergency without a prescription by a competent clinician Caution: Cautions and contraindications are relative as chlorphenamine is intended for use in life-threatening emergencies and its use should not be delayed. Side Effects: Drowsiness, headache, psychomotor impairment, urinary retention, dry mouth, blurred vision, local stinging or burning at the site of injection. Rapid IV administration may cause transient hypotension or paradoxical Central Nervous System (CNS) stimulation. Contraindications: Hypersensitivity to chlorphenamine or any of the excipients Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 5 of 26

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Hydrocortisone 100mg/1mL Injection Indications: Emergency (second-line) treatment of anaphylactic reaction. Status asthmaticus, acute allergic reactions, severe shock arising from trauma or infection, primary or secondary adrenocortical insufficiency, systemic lupus erythematosus or Stevens-Johnson syndrome. Adult Dose: 100mg to 500mg hydrocortisone by IM or slow IV injection. Dose may be repeated at intervals of 2, 4 or 6 hours as indicated by the patient's response. Instruction for Dilution: Depending on availability 1. Ampoule - None required 2. Solu-Cortef - reconstitute dry powder with diluent supplied according to instruction leaflet Route: IM (Intramuscular) or IV (Intravenous) Instruction for Administration: Administer by IM or slow IV injection over 3-5 minutes. For IV, flush with Sodium chloride 0.9% or Glucose 5%. Hydrocortisone must NOT be administered subcutaneously. Protocol: Can be administered in an emergency without a prescription by a competent clinician. Caution: History of severe psychiatric illness (especially steroid psychosis), diabetes mellitus, tuberculosis, renal insufficiency, epilepsy, hypothyroidism or pheochromocytoma. Side Effects: Anaphylactoid reactions, dyspepsia, nausea, vomiting, taste disturbances, muscle pain, bradycardia, hypotension, hypertension or increased sweating. Contraindications: Hypersensitivity to any components, systemic infections or live virus immunisation. Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 7 of 26

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Salbutamol 5mg/2.5mL Nebuliser Solution Indications: Treatment of acute severe asthma and the routine management of chronic bronchospasm unresponsive to conventional therapy Adult Dose: Salbutamol 5mg (2.5mL) Nebuliser Solution Instruction for Dilution: None required Route: Inhalation route only Instruction for Administration: via Nebuliser Mask with high flow oxygen/oxygen-driven Nebuliser. If oxygen not available give via air driven nebuliser. Protocol: Must be administered against a prescription or under a relevant Patient Group Direction (PGD) Caution: Salbutamol Nebuliser Solution should be used with caution in patients receiving other sympathomimetics. Treatment with salbutamol can lead to hypokalaemia. Tricyclic antidepressants may increase the risk of cardiovascular side effects. Corticosteroids may increase the risk of hyperglycaemia. Side Effects: Approx. 10% of patients can experience adverse reactions such as: taste alteration, mouth and throat irritation, burning sensation of the tongue, fine tremor (usually of the hands), nausea, sweating, restlessness, headache, dizziness and muscle cramps. In rare cases paradoxical bronchospasm may occur, manifest by an immediate increase in wheezing after dosing. Tachycardia, cardiac arrhythmias, palpitations, angina pectoris, blood pressure changes and stimulating effects on the central nervous system (hyper-excitability) Contraindications: Hypersensitivity to the active substance salbutamol or to the excipients Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 9 of 26

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Ipratroprium Bromide 500micrograms/2mL Nebuliser Solution Indications: For treatment of reversible airways obstruction in acute asthma and Chronic Obstructive Pulmonary Disease (COPD) when used concomitantly with Salbutamol. Should be administered to patients with a poor initial response to β 2 agonist (Salbutamol) therapy via nebuliser Adult Dose: 0.5mg (500micrograms)/2mL Nebuliser Solution Instruction for Dilution: None required Route: Inhalation only Instruction for Administration: via Nebuliser Mask with high flow oxygen/oxygen-driven Nebuliser. If oxygen not available give via air driven nebuliser Protocol: Must be administered against a prescription or under a relevant Patient Group Direction (PGD) Caution: Possible Immediate hypersensitivity reactions, narrow-angle glaucoma, with prostatic hyperplasia, bladder-outflow obstruction Side Effects: Headache, nausea (with or without vomiting) and dryness of the mouth Contraindications: Known hypersensitivity to atropine or ipratropium bromide Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 11 of 26

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Aspirin 300mg Tablet Indications: For acute coronary syndromes Adult Dose: Aspirin 300mg tablet single dose Instruction for Dilution: None required Route: Oral Instruction for Administration: Crushed/chewed, small drink of water may be taken after dose Protocol: Must be administered against a prescription or under a relevant Patient Group Direction (PGD) or protocol. Caution: Anticoagulants: the risk of bleeding is increased with aspirin due to the antiplatelet effect Past history of ulceration or dyspepsia Side Effects: May precipitate bronchospasm and induce asthma in susceptible patients. Rarely severe gastrointestinal haemorrhage, nausea, vomiting and increased bleeding tendencies. Anaphylactic reaction including shock. Contraindications: Active peptic ulceration or a history of peptic ulceration. Haemophilia, haemorrhagic disease or a history of bleeding disorders, gout/history of gout, hypersensitivity to aspirin (e.g. asthma, rhinitis, angioedema or urticaria), NSAIDs or other tablet excipients and during the third trimester of pregnancy. Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 13 of 26

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Glyceryl Trinitrate (GTN) 400microgram Spray Indications: Treatment of acute angina pectoris Adult Dose: Glyceryl Trinitrate: 1-2 metered dose(s) 400-800micrograms Instruction for Dilution: None required Route: Sublingual (under the tongue), whilst holding breath, do not inhale. Instruction for Administration: One or two metered doses, mouth should be closed immediately after each dose. Before using a new spray, press the pump button to ensure it is working. Protocol: Must be administered against a prescription or under a relevant Patient Group Direction (PGD) or Protocol Caution: Volume depletion from diuretic therapy, severe hepatic or renal impairment and hypothyroidism. The spray should not be inhaled. Alcohol may potentiate the hypotensive effect. Vasodilators, antihypertensives, β-blockers, calcium antagonists, neuroleptics, tricyclic antidepressants and diuretics can increase nitrate-induced hypotension Side Effects: Flushing, severe headache, vertigo, tachycardia, hypotension, fainting, nausea, vomiting, weakness, sweating and syncope Contraindications: Hypersensitivity to nitrates, severe hypotension (systolic blood pressure lower than 90mm Hg), severe anaemia, extreme bradycardia or concomitant use with phosphodiesterase inhibitors, such as sildenafil, tadalafil, or vardenafil. Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 15 of 26

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Glucagon 1mg/1mL injection when reconstituted (powder & Diluent) Indications: Treatment of severe hypoglycaemia for patients who are unconscious, unable to swallow or have not responded to oral therapy. Adult Dose: 1mg (1mL) Presentation: Glucagon comes as a dry powder in a vial. The diluent is supplied in a syringe (in the Glucagon Box) Instruction for Dilution: Preparing and giving the injection Twist box to open. 1. Remove the plastic cap from the vial. Pull the needle cover off the syringe. Do not remove the plastic back-stop from the syringe. Insert the needle through the rubber stopper (within the marked circle) of the vial containing GlucaGen and inject all the liquid from the syringe into the vial. 2. Without taking the needle out of the vial, gently shake the vial until GlucaGen has completely dissolved, and the solution is clear. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 17 of 26

3. Make sure the plunger is completely down. While keeping the needle in the liquid, slowly withdraw all the solution back into the syringe. Do not pull the plunger out of the syringe. It is important to remove any air bubbles from the syringe: With the needle pointing upwards, tap the syringe with your finger Push the plunger slightly to release any air that has collected at the top of the syringe. Continue to push the plunger until you have the correct dose for injection. A small amount of liquid will be pushed out when you do this. Route: IM (intramuscular)/ SC (Subcutaneous) Instruction for Administration: Glucagon should be given immediately after reconstitution. If no response within 10 minutes call (9)999 and doctor on call if not already summoned, as intravenous glucose may be required. Protocol: Can be administered in an emergency without a prescription by a competent clinician Caution: Close monitoring is necessary. Glucagon will not be effective in patients whose liver glycogen is depleted. Glucagon has limited effect in patients who have been fasting for prolonged periods, or suffering from adrenal insufficiency, chronic hypoglycaemia or alcohol induced hypoglycaemia. Side Effects: nausea, vomiting, abdominal pain, hypokalaemia, hypotension, rarely hypersensitivity reactions. Contraindications: Insulinoma and pheochromocytoma Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 18 of 26

Naloxone 400 microgram/1ml Injection Indications: 1. Management of suspected acute opioid/opiate overdose 2. Management of post-operative respiratory depression/use in palliative care Adult Dose: See instructions for administration Instruction for dilution: Dilution is not required if being administered for the acute management of overdose or opioid induced respiratory depression. Route: IV (intravenous), but if IV route is not available administer by IM (Intramuscular) or SC (sub-cutaneous) injection. Instruction for Administration: Management of suspected acute opioid/opiate overdose Give naloxone intramuscularly only if venous access is difficult, or if there is not someone present competent in IV injection. Remember that with IM administration the onset of action will be slower. The suggested initial dose is 400microgram (0.4mg), administered IM or IV. If there is no response then administer 800micrograms (0.8mg) for up to 2 doses at 3-5 minute intervals. If there is no response, a further dose of 2mg can be administered. A dose of 4mg may be required in severe poisoning. If there is no response, review diagnosis. The maximum total recommended dose is 10mg. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 19 of 26

Management of respiratory depression/use in palliative care USES LOWER INITIAL DOSING REGIME SUITABLE FOR USE : o IN PALLIATIVE CARE, o CHRONIC OPIOID/OPIATE USE FOR PAIN RELIEF Initially administer 100-200microgram (1.5-3 micrograms/kg) by IV injection. Titrate the dose to patient response If response inadequate give subsequent doses by IV injection of 100 micrograms. Allow a full 2 minutes to elapse between 100 microgram increments. ALTERNATIVELY administer by IM injection 100 micrograms every 1-2 hours. BE AWARE THAT ANALGESIA WILL ALSO BE REVERSED. MONITOR FOR INCREASED PAIN, DISTRESS, WITHDRAWAL SYMPTOMS Protocol: Can be administered without a prescription in an emergency when a patient s life is at risk by staff competent in naloxone administration up to a dose of 400micrograms (1mL). Cautions: Should be used with caution in: Patients with cardiac disease as it can cause hypotension, hypertension, tachycardia, arrhythmias and very rarely ventricular fibrillation and death Pregnant women who are opioid dependent as a withdrawal reaction can be precipitated in the foetus. Note that in pregnancy in a lifesaving situation, naloxone must ALWAYS be administered. Side effects: Include nausea, vomiting, dry mouth, diarrhoea, pulmonary oedema, dizziness, tremor, sweating, seizures, tension, hyperventilation, post-operative pain and very rarely, anaphylaxis and erythema multiforma. Further Medicine information can be obtained from the BNF, OHFT website MEDICINES (Green) Button &ToxBase Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 20 of 26

Midazolam 10mg/1mL Buccal Liquid Indication: Treatment of prolonged or repeated (serial) seizures Adult Dose: 10mg (1mL) to be administered into the buccal cavity Presentation: 5mL of liquid (sufficient to deliver 4 x 1mL doses), 4 x 1mL oral syringes Instruction for Dilution: Not required Route: Buccal administration Instruction for Administration: Open the bottle and hold upright Insert the 1mL oral syringe into the bottle Invert the bottle and oral syringe Draw out the prescribed volume Support the patient s head and chin Administer about half the volume between the lower gum and cheek on one side of the mouth and the remaining volume between the gum and cheek on the other side of the mouth Do NOT administer under the tongue Support the cheek and lips whilst giving buccal midazolam and afterwards to minimise leakage from mouth (see diagram) Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 21 of 26

The effect of midazolam should be apparent after approximately 5 minutes and seizure should have terminated within ten minutes. Maintain observations, monitor airways and breathing Protocol: Must be administered against a prescription or under a relevant Patient Group Direction (PGD) by a competent clinician. Caution: Midazolam should be used with caution in patients with chronic respiratory insufficiency because midazolam may further depress respiration, patients with chronic renal failure, impaired hepatic or cardiac function. Midazolam should be avoided in patients with a medical history of alcohol or drug abuse Side Effects: Sedation, Sleepiness or drowsy, depressed levels of consciousness, respiratory depression, nausea and vomiting Contraindications: Hypersensitivity to the midazolam, myasthenia gravis, severe respiratory insufficiency, sleep apnea syndrome, severe hepatic impairment Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 22 of 26

Flumazenil 100microgram/mL Injection in 5mL Ampoule Indications: Management of benzodiazepine toxicity where reduced respiratory rate (<10 breaths per minute) or O2 saturation < 90% NOTE: Flumazenil is unlicensed for management of benzodiazepine toxicity. The doses listed are as recommended by the UK National Poisons Information Service 1, 2 Adult dose 1, 2 : FIRST DOSE: Administer 0.5mg/5mL (500micrograms/5mL) of flumazenil via IV injection over 15 seconds Wait 30 seconds. If unsuccessful or only partially successful, give SECOND DOSE: Administer 0.5mg/5mL (500micrograms/5mL) of flumazenil via IV injection over 15 seconds Wait 30 seconds. If unsuccessful or only partially successful, give THIRD DOSE: Administer 1mg of flumazenil via IV injection over 15 seconds If there is no response after the patient has received a total dose of 2mg within a few minutes it is unlikely that flumazenil will reverse the CNS/respiratory depression. Not more than 3mg (3000micrograms) as a bolus loading dose should be given within one hour. If drowsiness recurs, or there is inadequate airway protection and reduced ventilation, bolus doses (0.5-1.0mg [500-1000micrograms]) can be given and repeated at 20-minute intervals. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 23 of 26

Route: IV (intravenous) bolus dose Instructions for dilution: Dilution is not required for emergency administration. Protocol: Only to be administered by a DOCTOR who, in their professional opinion, is competent to use it safely. Caution: Only to be used in benzodiazepine overdose. Do not use in cases of mixed overdose. Carefully titrate dose in hepatic impairment. Use with caution in patients with a history of seizures, head injury or chronic benzodiazepine use. Flumazenil has a shorter half-life than benzodiazepines e.g. diazepam or lorazepam. Respiratory rate may recover, but then deteriorate again. If respiratory rate does not return to normal or patient is not alert after initial doses have been given, assume that sedation is due to another cause. Side Effects: Hypersensitivity reactions (including anaphylaxis) have rarely been reported and nausea and vomiting (occasionally). If patients are awakened rapidly they may become agitated, anxious or fearful. Contra-indications: Hypersensitivity to flumazenil. Patients receiving benzodiazepines for control of a potentially life-threatening condition (e.g. control of intracranial pressure or status epilepticus). Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Reference: 1. UK National Poisons Information Service, Naloxone- antidote. Updated July 2015, accessed May 2016 2. Personal Communication from UK National Poisons Information Service. September 2016 Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 24 of 26

Furosemide 50mg/5mL Injection Indications: Conditions requiring prompt diuresis, where oral therapy is precluded. Include cardiac, pulmonary, hepatic and renal oedema. Adult Dose: 20-50mg to be given by slow IV injection at a rate not exceeding 4mg/minute. Doses above 50mg must be given by IV infusion Instruction for Dilution: None required For IV injection. For IV infusion dilute with Sodium chloride 0.9% Route: Intravenous (IV) or Intramuscular (IM) Instruction for Administration: By slow IV injection/infusion at a rate not exceeding 4mg/minute. For IV flush with Sodium chloride 0.9%. Doses of 20-50mg may also be administered by IM injection. Furosemide must NOT be administered subcutaneously Protocol: Must be administered against a prescription or relevant Patient Group Direction (PGD) by a competent clinician Caution Should be used with caution in patients with partial obstruction of urinary outflow, hypotension, gout, hyperuricemia, co-administration with lithium salts and acute porphyria. Monitor blood pressure, fluid balance and electrolytes. Side Effects: Hypersensitivity reactions, purpuric and urticarial rashes discontinue furosemide immediately. Fluid and electrolyte depletion may occur, causing headache, dizziness, confusion, weakness, hypotension, dehydration, circulatory collapse, haemoconcentration and thrombosis, cardiac arrhythmias and cramps. Rapid administration and high doses may cause tinnitus and deafness. Acute urinary retention may occur, ensure urinary output is secured. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 25 of 26

May cause thrombophlebitis Contraindications: Hypersensitivity to furosemide, amiloride or sulphonamide derivatives. Hypovolaemia, dehydration, severe hypokalaemia or hyponatraemia. Breast-feeding women. Further Medicine information can be obtained from the BNF or the OHFT website MEDICINES (Green) Button. Quick Reference Guide v2.0 (Pharmacy & Resuscitation Departments) Page 26 of 26