AEA - Ambulance Emergency Assistant - Protocols

Module ILS PRACTITIONER PROTOCOLS

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1 ACETYL SALICYLIC ACID

1.1 Acetyl Salicylic Acid ( AKA Aspirin)

Classification: Non-steroidal anti-inflammatory / platelet aggregation inhibitor Schedule: 0

1.2 PharmaCOLOGY Action

Aspirin inhibits the enzyme cyclo-oxygenase thus inhibiting the production of prostaglandins including

thromboxane; it has no effect on leukotriene production.

Cyclo-oxygenase (COX), officially known as prostaglandin-endoperoxide synthase (PTGS), is an enzyme that is responsible for formation of prostanoids, including prostaglandins, prostacyclin and thromboxane.

(They act in the formation of blood clots and reduce blood flow to the site of a clot.)

1.3 Adverse Effects

Anaphylactic reaction o some patients, especially asthmatics exhibit notable sensitivity to aspirin, which may provoke

various hypersensitivity / allergic reactions

Potential bronchoconstriction in asthmatics

Gastric mucosa irritation o dyspepsia; peptic ulceration; peptic bleeding

Bleeding tendency

Foetal distress due to obliteration of foetal ductus arteriosus

Suppression of uterine contractions

1.4 Indication

Suspected MI (Myocardial Infarction)

1.5 Contra Indication

Known hypersensitivity / allergy to aspirin

Peptic ulceration with active bleeding

Bleeding tendency

Patients already receiving Platelet Aggregation Inhibitors or Anticoagulants

Pregnancy

Children


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2 ACTIVATED CHARCOAL

2.1 Activated Charcoal

Classification: Carbon Schedule: 1

2.2 PharmaCOLOGY

Study of properties & effects of drugs Pharmacology effects: Therapeutic Effects (desirable) Side Effects (undesirable / harmful)

Activated Charcoal absorbs many poisonous compounds to its surface this reduces the absorption by the GIT (Gastro-Intestinal Tract)

2.3 Adverse Effects

The patient may experience mild constipation

2.4 Indication

To assist in treatment of certain cases if overdoses and poisonings where agents/s have been orally ingested (ONLY within an hours of ingestion)


Should NOT be used with poisoning with: Boric Acid Cyanide Ethanol Ethylene Glycol Lithium Methanol Organophosphates Petroleum Products Iron Strong acids and Alkalis When a pt. has decreased levels of consciousness or is unconscious

Unprotected airway DO NOT USE if he container was not sealed properly De-activation due to moisture exposure)

2.6 Packaging

Powder: Fine black powder in bottles of 25g and 50g

2.7 Dosage and Administration

Adult: 1g / kg mixed with water, given orally Paediatric: 0.5g / kg mixed with water, given orally


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3 2 STIMULANTS

3.1 2 stimulants / Adrenergic Stimulants

Classification: Bronchodilators Schedule: 2: Aerosol

3: Inhalant solutions and unit dose vials


Fenoterol & Salbutamol are selective 2 stimulants acting on the 2 receptors in the lungs: o bronchial smooth muscle: bronchodilation

At higher/repeated dosages, the systemic absorption progressively increases, thus acting on other organs with 2 receptors e.g.

o Skeletal muscle : contraction o Vascular smooth muscle : vasodilation o Bladder smooth muscle : relaxation o Intestinal smooth muscle : decreased peristalsis o Uterine smooth muscle : tocolysis o Glycogen stores : break down of glycogen to glucose

At higher/repeated dosages, the selectivity is also progressively lost and 1 effects (myocardium) are experienced:

o Positive inotrope o Positive chronotrope o Positive dromotrope o Increased myocardial oxygen consumption

3.3 Pharmaco-KINETICS

Onset of action : 5-15 minutes Duration of action : 3-6 hours

3.4 Adverse Effects

Tremors, restlessness, anxiety, confusion, headache

Hypotension

Tachycardia, palpitations

Cramps

Nausea, vomiting

Urinary retention

Tocolysis

Hyperglycaemia

Hypokalaemia

3.5 Indication

Acute bronchospasm


Known hypersensitivity / allergy to 2 stimulants

Neonates

3.7 Precautions

Special caution must be used when pulse rate exceeds 120 beats / minute

3.8 Packaging

Fenoterol:


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o Berotec aerosol: 100g o Inhalant solution: 1mg/ml o UDV: 1.25mg/2ml or 0.5mg/2ml

Salbutamol: o Ventolin aerosol: 100g o Resp. solution: 5mg/ml o UDV / nebules: 2.5mg/2.5ml or 5mg/2.5ml

Hexoprenaline o Discontinued Sulphate

3.9 Administration and Dosages

A. ACUTE BRONCHOSPASM

Aerosol o 6 10 puffs should be administered during an episode o may then be repeated every 15 minutes, using a spacer

Inhalant solution: (use half the dosage for paediatrics) o 2ml Fenoterol (1.25mg/2ml)(UDV) + 3ml N/S o 2ml Fenoterol (0.5mg/2ml) (UDV) + 3ml N/S (paediatric solution) o 1ml Fenoterol solution (1mg/ml) + 4ml N/S o 1ml Salbutamol (5mg/ml) + 4ml N/S o Repeat continuously if necessary

Unit Dose Vials o UDV + N/S diluted up to 5ml

4 IPRATROPIUM BROMIDE

4.1 Ipratropium Bromide

Classification: Bronchodilators - anticholinergic Schedule: 2


Ipratropium bromide causes relaxation of bronchial muscles due to its anticholinergic effects o (blocks parasympathetic system)

Its bronchodilation action is particularly effective in conjunction with 2-stimulants

4.3 Pharmaco-KINETICS

Onset of action : 30 minutes Duration of action : 4-6 hours

4.4 Adverse Effects

With larger / repeated dosages o it is absorbed from the lungs into the systemic circulation resulting in systemic anti-cholinergic

effects Tachycardia Dry, hot skin Mydriasis Urinary retention


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4.5 Indication

To be used in conjunction with 2-stimulants for acute bronchospasm


Known hypersensitivity to ipratropium bromide or other anti-cholinergic drugs Do not use in neonates

4.7 Precautions

The onset of action is only after 20 minutes, which is much longer than the 2-stimulants o peak effectiveness at 60 90 minutes

The duration of action is 4 - 6 hours, which is also longer than the 2-stimulants

4.8 Packaging

Unit dose vial (UDV) containing 0.25 mg/2ml or 0.5 mg/2ml Metered Dose Inhaler (300 doses) 40 g / inhalation (0.04mg) Nebulizer solution (bottle) 0.25mg/ml


Adults

UDV o Ipratropium bromide 0.5mg o + appropriate 2 stimulant o + balance of N/S to a o total of 5ml solution

Nebulised over 10 minutes Aerosol

o The patient or ILS Provider may administer this during an episode. o Two puffs of ipratropium bromide are administered if no improvement occurs following 2

stimulant administration Use of a spacer device is recommended. Children > 5 years

UDV o Ipratropium bromide 0.5mg o + appropriate 2 stimulant o + balance of N/S to o total of 5ml solution

nebulised over 10 minutes Children 1 to 5 years :


nebulised over 10 minutes Children > 1 month to 1 year :


nebulised over 10 minutes


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4.10 NOTE

Ipratropium bromide + 2 stimulant have a synergistic effect May be particularly useful in patients with bronchospasm who have taken beta-blockers Typically given only once because of its prolonged onset of action; higher doses than those advocated

above, or dosing intervals less than four hours confer no added benefits.

5 DEXTROSE 50%

5.1 Dextrose (Carbohydrate)

Classification: Carbohydrate Schedule: 1


Glucose is a monosaccharide o the most basic unit to which all carbohydrates are broken down o and glucose is thus immediately available as a source of energy

5.3 Adverse Effects

Local irritation of vein

Thrombophlebitis

Local tissue necrosis

Hyperosmolarity

Diuresis

Hyperglycaemia

5.4 Indication

Acute management of symptomatic hypoglycaemia

Blood glucose < 3.5mmol/L and patient is clinically symptomatic

Decreased level of consciousness of unknown cause, with suspicion of associated hypoglycaemia / blood glucose < 3.5mmol/L


There are no absolute contra-indications in the presence of true symptomatic hypoglycaemia

Do not administer dextrose routinely during resuscitation unless there is confirmed hypoglycaemia

5.6 Precautions

Dehydration and hypovolaemia o High concentrations of IV dextrose cause an increase in osmolality that draws H2O from the cells

and causes diuresis, aggravating dehydration o Dehydration / hypovolaemia and hypoglycaemia must be corrected simultaneously

Intracranial haemorrhage o Glucose leaking into the cerebral tissue will aggravate the injury and result in cerebral oedema o Careful titration in all head injured patients is vital

5.7 Complications and adverse effects may be diminished by:

Limiting the use of dextrose to symptomatic hypoglycaemic patients Administering dextrose slowly through a free-flowing IV line Re-assessing the blood glucose 5 minutes post administration Avoiding hyperglycaemia Never combining dextrose and sodium bicarbonate in the same infusion (i.e. hyperosmolarity)


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5.8 Packaging

20ml & 50ml ampoules of a 50% solution (0.5g/ml) 50ml vacolitre containing a 50% solution


Adults 10g (20ml of 50% solution) slowly IVI Repeat every 5 minutes should blood glucose remain < 3.5mmol/l

Children (> 8years of age) 1ml/kg of a 50% solution which is then diluted to a 12.5% solution with sterile water Repeat every 5 minutes should blood glucose remain < 3.5mmol/l

NOTE If blood glucose remains < 3.5mmol/l after 3 doses, reassess patient, equipment and administration

technique Treat the patient and not the test result

6 ORAL GLUCOSE POWER / GEL

6.1 Oral Glucose Powder / Gel

Classification: Carbohydrates Schedule: 1

6.2 PharmaCOLOGY


Administration of oral glucose solution / preparation provides soluble (simple) carbohydrate to tissues in order to raise Blood Glucose Levels.

6.3 Adverse Effects

Hyperglycaemia

6.4 Indication

Acute management of Hypoglycaemia HGT


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7 MEDICAL OXYGEN

7.1 Medical Oxygen

Classification: Natural Occurring Atmospheric Gas

7.2 PharmaCOLOGY


Colourless, tasteless, odourless gas

Present in atmosphere approx. 21% local atmospheric pressure

Reverses deleterious effects of hypoxeamia on the brain, heart and other vital organs o (decrease amount of oxygen in tissue)

Expired air contains 16%-17% oxygen

During optimal active CPR only 25%-30% of normal cardiac output is maintained and for these reason supplemental oxygen should be administered o Good CPR with supplement O2 you can maintain normal cardiac output of 25-30%

7.3 Indication

GCS (Glasgow Coma Scale)


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7.6 Packaging

Pressurised cylinder containing 100% medical oxygen


Administered via: Oxygen masks Simple Mask Venturi Mask Partial Re-Breather Mask Non-Re-Breather Mask Nasal cannulae Nebulizer device (5ml of saline) Jet insufflation Bag-Valve Mask/Tube (BVM) Bag-Valve Mask/Tube Reservoir Device Correct Flow rates (FiO2):

Nasal Cannulae 21-40% @ 1 6 L/min

Venturi Mask 24-50% @ 4 12 L/min

Simple Mask 35-60% @ 6 10 L/min

Partial Re-Breather Mask 35-70% @ 6 10 L/min

Non-Re-Breather Mask 60-100% @ 6 15 L/min

Bag-Valve-Mask/tube 50% @ 12 15 L/min

Bag-Valve-Mask/tube reservoir device 95-100% @ 15 L/min

(Adequate flow rate = Reservoir bag inflated > 1/3 at all time) Just under 1/3.

8 ENTONOX - NITROUS OXIDE AND OXYGEN

8.1 Entonox Nitrous Oxide and Oxygen

Classification: Analgesic Gas Schedule: 4

8.2 PharmaCOLOGY


Colourless, sweet-smelling, non-irritant gas

Heavier than room air / oxygen

Mild analgesic and anaesthetic effect depending on the dose inhaled

When inhaled it supressed the CNS (Central Nervous System) causing anaesthesia

High concentrations of oxygen delivered along with nitrous oxide INCREASES oxygen tension in the blood thereby REDUCING hypoxia (Hypoxia lack of oxygen)

Provides rapid, easily reversible relief of mild to moderate pain relief

8.3 Pharmaco-KINETIC

HOW the body HANDLES the drug over period of time:

Absorption o Absorption begins at site of administration o RATE and EXTENT of absorption depends on:

Route of administration Dosage


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Dosage form

Distribution o distribution is transport of the drug through blood stream to various tissues at its action site o Barriers to drug distribution: blood barriers / placental barrier

Biotransformation o Process: drug is chemically converted to a metabolite (in order for body to metabolize drug)

Excretion o Is elimination of toxic / inactive metabolites o Kidneys primary organ for excretion o Other organs: intestine / lungs / glands / skin

Above effects pt. response to drug therapy

EXTREMELY bloods-insoluble

NOT metabolised by the body

Eliminated by the lungs (small amounts eliminated through skin)

Onset action: 30-60 sec (MAX 3-4 min) o Can last for up to 10 min

8.4 Adverse Effects

Light-headedness Drowsiness Nausea and Vomiting

8.5 Indication

Relief from pain from: o Acute Myocardial Infarction o Musculoskeletal trauma o Burns NOT burn to respiratory tract o Active labour

Any other condition requiring pain relief PROVIDED THERE ARE NO CONTRA - INDICATIONS


GCS (Glasgow Coma Scale)


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o Once in gas-containing space the gas dissociates and NITROGEN diffuses OUT SLOWER than NITROUS OXIDE diffuses IN

o Causes a NET INCREASE in GAS VOLUME

When masked is removed after prolonged use o gas will come out of solution in lungs and displace the oxygen in the alveoli causing

hypoxia o Prevention: Mask must NOT be strapped to pt. face. Pt. must receive oxygen for 5-10min

Nitrous oxide is a NON-explosive gas

8.8 Packaging

Pressurised cylinders: mixture 52% nitrous oxide + 48% oxygen (N2O+O2 52%: 48%)


Entonox is predominantly a self-administered gas Administration is to be explained carefully to pt. beforehand prevent unnecessary complications Once pt. has inhaled enough Entonox to control the pain, they must remove the mask preventing chances of overdosing If pt. becomes drowsy REMOVE Entonox and replace immediately with oxygen ONLY registered ALS may administer Entonox to pt. As it require careful monitoring of pt. in order to prevent complications arising.


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AEA - Ambulance Emergency Assistant - Protocols

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