1
Q
Where are the adrenal glands located?
A
1 on top of each kidney
2
Q
What is the outer part of the adrenal gland called?
A
adrenal cortex
3
Q
What is the inner part of the adrenal gland called?
A
adrenal medulla
4
Q
What are the three zones of the adrenal cortex?
A
Zona Glomerulosa
Zona Fasciculata
Zona Reticularis
5
Q
What does the Zona Glomerulosa (outer zone) of the adrenal cortex do?
A
- Produces mineralocorticoids, mainly aldosterone which acts on the distal nephron and augments Na+ reabsorption & K+ and H+ excretion
- Influences extracellular fluid space and blood pressure through sodium balance
6
Q
What does the Zona Fasciculata (middle zone) of the adrenal cortex do?
A
- Produces glucocorticoids, predominantly cortisol, increasing blood sugar levels via gluconeogenesis & suppresses the immune system and aids metabolism
- This zone secretes cortisol both at a basal level and as a response to the release of adrenocorticotropic hormone (ACTH) from the pituitary gland
7
Q
What does the Zona Reticularis (inner zone) of the adrenal cortex do?
A
- Produces gonadocorticoids and is responsible for administering these hormones to the reproductive regions of the body.
- Most of the hormones released by this layer are androgens.
- The main androgen produced by this layer is
8
Q
What is dehydroepiandrosterone (DHEA)?
A
the most abundant hormone in the body and serves as the precursor for many other important hormones produced by the suprarenal gland, such as oestrogen, progesterone, testosterone and cortisol.
9
Q
What hormones does the adrenal medulla produce?
A
Adrenaline
Noradrenaline
(Fight or flight hormones)
10
Q
What does adrenaline do?
A
rapidly responds to stress by increasing the heart rate and redistributing blood to the muscles and brain. It also increases blood sugar level by converting glycogen to glucose in the liver.
11
Q
What is glycogen?
A
the liver’s storage form of glucose
12
Q
What does noradrenaline do?
A
works with adrenaline in response to stress, however it can cause vasoconstriction resulting in hypertension
13
Q
What is hydrocortisone?
A
Cortisol
14
Q
What does hydrocortisone (cortisol) do?
A
- regulates how the body converts fats, proteins and carbohydrates into energy
- helps regulate blood pressure and cardiovascular function
- controls the intermediary metabolism
- moderates immune response
- is essential for the resistance of the organism to noxious stimuli
15
Q
What does the hormone corticosterone do?
A
works with hydrocortisone to regulate immune response and suppress inflammatory reactions
16
Q
What is the pathophysiology of secondary adrenal insufficiency?
A
the pituitary gland fails to produce enough adrenocorticotropin (ACTH) to stimulate the adrenal glands to produce cortisol, shrinking the adrenal glands
secondary adrenal insufficiency is much more prevalent than Addison’s disease.
17
Q
What is the pathophysiology of iatrogenic adrenal insufficiency (subgroup of secondary)?
A
caused by chronic long-term corticosteroid use and can occur following withdrawal from 2 weeks or more of corticosteroid use or as doses are tapered
18
Q
What are the most common symptoms of adrenal insufficiency?
A
chronic, or long lasting, fatigue
muscle weakness
loss of appetite
weight loss
abdominal pain
19
Q
What are the least common symptoms of adrenal insufficiency?
A
nausea, vomiting, diarrhoea
low blood pressure that drops further when a person stands up, causing dizziness or fainting
headache, irritability and depression
craving salty foods
hypoglycaemia, or low blood sugar
sweating
in women, loss of interest in sex, irregular or absent menstrual periods
20
Q
What are the symptoms of an adrenal crisis?
A
General: High fever weakness, lethargy, weight loss, joint or muscular pain
CNS: fatigue, disorientation, headache, mood change, mental confusion
Gastro: abdominal pain, nausea, vomiting and diarrhoea
CVS: tachycardia, Low BP, postural hypotension, dehydration, syncope
Skin: hyperpigmentation of skin or buccal mucosa,mottled appearance indicating peripheral shutdown, pallor
Electrolytes: hypoglycaemia, hyperkalaemia (high potassium) , hyponatraemia (low salt)
21
Q
What is an adrenal crisis?
A
Sudden, severe worsening of adrenal insufficiency symptoms is called adrenal crisis
22
Q
What is the pathophysiology of asthma?
A
- immune system activated causing inflammatory mediators released
- inflammation of lower airway causing irritation and mucosal oedema resulting in turbulent air flow
- bronchoconstriction increases residual volume, PCO2, air trapping and alveolar pressure and reduces oxygen rich air to alveoli causing decreased blood oxygenation
23
Q
What is the pathophysiology of primary adrenal insufficiency (Addison’s Disease)?
A
adrenal glands don’t release aldosterone cortisol and adrenal androgens to meet physiologic needs, despite release of ACTH from the pituitary
24
Q
What are the 2 phases of asthma?
A
Acute (early) phase - 1st 60 mins post stimulus exposure
Late phase - 4-8hrs post stimulus exposure
25
What cells does immunoglobulin E (IgE) bind to in the acute phase of asthma?
basophils
lymphocytes
mast cells
26
the acute phase of asthma, what happens when immunoglobulin E (IgE) binds to basophils, lymphocytes and mast cells?
it can stimulate the immune system causing MAST cells to release mediators such as histamine, leukotrienes and prostaglandins
27
In the acute phase of asthma, what do histamine, leukotrienes and prostaglandins cause?
* spasm of the bronchial smooth muscle in the small and middle airways (causing the wheeze)
* oedema and mucous secretions
* vascular permeability resulting in inflammation.
28
What causes the late phase of asthma?
the release of chemotaxins from the MAST cells which attract inflammatory cells to try to eliminate the irritant
29
In the late phase of asthma, what inflammatory cells are attracted by the chemotaxins in the MAST cells?
eosinophils
neutrophils and
macrophages
30
What is the result of the inflammatory process of the late phase of asthma?
vasodilation, mucous secretion, bronchospasm, plasma leak and oedema which worsens clinical symptoms by promoting airway inflammation, obstruction and hyper-responsiveness
31
What is the treatment for anaphylaxis in a Pt who has had adrenaline administered prior to paramedic arrival and their symptoms have resolved?
Continual reassessment as they may deteriorate
Minimise time on scene
DO NOT ALLOW THE PATIENT TO STAND OR WALK
POSTURE PT SUPINE (sitting with legs straight out if breathing difficulties are present)
32
What are the signs and symptoms of mild/moderate asthma?
* Can walk, speak whole sentences in one breath (for young children can move around and speak in phrases)
* SpO2% > 94% room air
* Pulse rate < 100/min Adult and Paed
* PEFR >75% of predicted Adult and > 60% Paed of predicted or best (if known) or cannot be performed
33
What are the signs and symptoms of severe asthma?
* Unable to complete sentences in one breath due to dyspnoea
* SpO2% 90-94% room air
* Pulse rate 100-120/min Adult and 100-200/min Paed
* Accessory muscle use or ‘tracheal tug’ during inspiration or subcostal recession (abdominal breathing)
* Obvious respiratory distress
* PEFR 50-75% Adult and 40-60% Paed of predicted or best (if known) or cannot be performed
34
What are the signs and symptoms of life-threatening asthma?
* Talks in words
* SpO2% <90% room air
* Pulse rate > 120/min Adult and > 200/min Paed (bradycardia present when respiratory arrest is imminent)
* Poor respiratory effort, soft/absent breath sounds
* Reduced consciousness or collapse
* Exhaustion/agitation
* Cyanosis
* PEFR <50% Adult and < 40% Paed of predicted or best (if known) or cannot be performed
35
What are the 2 types of signs and symptoms in hypoglycaemia?
adrenergic
neuroglycopaenic
36
What are the adrenergic symptoms of hypoglycaemia?
trembling or shaking
diaphoresis
lightheadedness
numbness around lips and fingers
hunger
37
What are the neuroglycopaenic symptoms of hypoglycaemia?
reduced LOC
dizziness
headache
lack of concentration
weakness
behavioural change
irritability
tearfulness/crying
38
What are the P5 exclusions for hypoglycaemia?
alone/no carer
unable/unwilling to eat
pregnancy
unresponsive or inadequate response to treatment
39
Why do paramedics need to notify triage of glucose administration in hypoglycaemic Pts with known or suspected ETOH?
It may precipitate Wernicke's encephalopathy
40
What is the treatment for hypoglycaemia in Pts 28days of age or greater who are conscious and can swallow?
Assist to eat and drink (if available)
Glucose gel if food or drink not available
Monitor for 15 mins and retest BGL
Repeat treatment once if inadequate or nil response to treatment
Determine disposition or transport if P5 exclusions
41
What is the treatment for hypoglycaemia in Pts <28 days of age who are uncconscious and/or unable to swallow?
Glucose 10%
Glucagon if unable to administer glucose gel 10%
Monitor for 15 mins and retest BGL
Repeat treatment once if inadequate or nil response to treatment
Determine disposition or transport if P5 exclusions
42
What is the treatment for hypoglycaemia in Pts <28days of age who are conscious and can swallow?
Assist to feed (if available)
Administer glucose gel if breast milk/formula not available
Monitor for 15 mins and retest BGL
Repeat treatment once if inadequate or nil response to treatment
Determine disposition or transport if P5 exclusions
43
What is the treatment for hypoglycaemia in Pts 28 days of age or greater who are unconscious and/or unable to swallow?
Glucose 10%
Glucagon if unable to administer glucose gel 10%
Monitor for 15 mins and retest BGL
Repeat treatment once if inadequate or nil response to treatment
Determine disposition or transport if P5 exclusions
44
What are the indications for treatment for hyperglycaemia?
* BGL 17mmol or greater
* moderate to severe dehydration
45
What are the signs and symptoms of hyperglycaemia?
Confusion
Acetone breath
Tachycardia
Hypotension
Kussmaul's respiration
Vomiting
46
What is the treatment for indicated hyperglycaemia?
compound sodium lactate
treat signs and symptoms as per specific protocol
transport to ED
47
Do you transport non indicated hyperglycaemic Pts to ED?
yes
48
What are the signs and symptoms of anayphylaxis?
Any ONE or MORE of the following:
* Persistent dizziness or collapse
* Pale and floppy (young children)
* Swelling of the tongue
* Swelling/tightness in the throat
* Difficulty talking/hoarse voice
* Difficult/noisy breathing
* Wheeze or persistent cough
* Persistent abdo pain and vomiting after exposure to a likely allergen (including injected medications and insect bites/stings)
49
What are the signs and symptoms of adrenal crisis?
Reduced alertness, confusion
Lethargy, pallor, weakness
Tachycardia
Hypotension, peripheral shutdown
Hypoglycaemia
Nausea, vomiting, abdominal pain
50
What are the potential precipitants of adrenal crisis?
Any significant illness, trauma or stress, including:
Febrile illness, infection, gastroenteritis.
Respiratory distress, abdominal pathology, labour.
Injury, trauma, environmental exposure.
Severe psychological stress.
Non-compliance with regular hydrocortisone.
51
What is the management for adrenal crisis?
Hydrocortisone
Treat other signs and symptoms
Monitor BP
Transport to ED
Note: IV access will be easier post hydrocortisone administration
52
What is intestinal malrotation
a birth defect where the intestine does not make the turns as it should.
* It occurs equally in boys and girls
* More boys have symptoms by the first month of life
53
What is a volvulus?
A volvulus is a problem that can occur after birth as a result of intestinal malrotation. The intestine becomes twisted, causing an intestinal blockage that prevents food from being digested normally. This blockage can also cause dehydration. This twisting can also cut off the blood flow to the intestine, and the intestine can be damaged
54
What is the 5yrs & older salbutamol NEB dose for mild to moderate asthma?
5mg
Whilst indicated
No max dose
55
What is the 5yrs & older salbutamol MDI dose for mild to moderate asthma?
4-12 puffs
whilst indicated
no maximum dose
56
What is the 5yrs & over salbutamol NEB dose for severe asthma?
5mg
Whilst indicated
No max dose
57
What is the 4yrs & under salbutamol NEB dose for life threatening asthma?
2.5mg
Whilst indicated
No max dose
58
What is the 4yrs & under salbutamol NEB dose for mild to moderate asthma?
2.5mg
Whilst indicated
No max dose
59
What is the 4yrs & under salbutamol MDI dose for mild to moderate asthma?
2-6 puffs
whilst indicated
no maximum dose
60
What is the 5yrs & older salbutamol MDI dose for severe/life threatening asthma?
12 puffs
whilst indicated
no maximum dose
61
What is the 4yrs & under salbutamol MDI dose for severe/life threatening asthma?
6 puffs
whilst indicated
no maximum dose
62
What is the 4yrs & under salbutamol NEB dose for severe asthma?
2.5mg
Whilst indicated
No max dose
63
What is the 5yrs & over salbutamol NEB dose for life threatening asthma?
5mg
Whilst indicated
No max dose
64
What is the ≥6 yrs ipratropium bromide NEB dose for severe to life threatening asthma?
500mcg mixed with salbutamol
repeated once
total max dose 1mg
65
What is the ≥2 yrs - <6 yrs ipratropium bromide NEB dose for severe to life threatening asthma?
250mcg
repeated once
total max dose 500mcg
66
What is the ≥6 mths - <2 yrs ipratropium bromide NEB dose for severe to life threatening asthma?
125mcg
repeated once
total max dose 250mcg
67
What is the ≥16 adrenaline IM dose for cardiac arrest?
1mg
every 2nd cycle (approx 4 mins)
no max dose
68
What is the ≥16yrs glucagon IM dose for hypoglycaemia (BGL < 4mmol & ↓ LOC & unable to be cannulated for glucose 10%)
1mg
single dose only
69
What is the <16yrs glucagon IM dose for hypoglycemia (BGL < 4mmol & ↓ LOC & unable to be cannulated for glucose 10%)
0.5mg
single dose only
70
What is the ≥10yrs glucose 10% IV dose for hypoglycaemia (BGL < 4mmol & ↓ LOC)
15g bolus
whilst indicated
no max dose
71
What is the <10yrs glucose 10% IV dose for hypoglocaemia (BGL < 4mmol & ↓ LOC)
0.2g/kg bolus (max bolus 15g)
whilst indicated
no max dose
72
What is the ≥1yr PO dose of glucose gel for hypoglycaemia?
15g bolus
repeated once at 15 mins
total max dose 30g
73
What is the <1yr PO dose of glucose gel for hypoglycaemia?
small aliquots via gloved finger up to 15g
single dose only
74
What is the all age IV dose of compound sodium lactate for hyperglycaemia?
10mL/kg bolus
Whilst indicated
No max dose
75
What is the all age IV dose of compound sodium lactate for dehydration?
10mL/kg bolus
single dose only
76
What is the adult IM dose of midazolam for seizures?
5mg bolus
every 5 mins
total max dose 15mg
77
What is the paediatric NAS dose of midazolam for seizures?
0.3mg/kg (single max dose 5mg)
single dose only
78
What is the paediatric IM dose of midazolam for seizures?
0.15mg/kg (max bolus 5mg)
every 5 mins
total max dose 0.45mg/kg
79
What is the adult IV/IO dose of midazolam for seizures?
2.5mg diluted slow bolus
every 5 mins
total max dose 15mg
80
What is the paediatric IV/IO dose of midazolam for seizures?
0.15mg/kg diluted (max bolus 0.15mg/kg)
every 5 mins
total max dose 0.45mg/kg
81
What is the 16yrs or older aspirin dose for ACS?
300mg
chewed and followed by small sip of water
single dose only
82
What is the 16yrs & older GTN dose for ACS?
600mcgs
every 5 mins
total max dose
1.8mg (3 doses)
83
What is the 16yrs & older IV fentanyl dose for analgesia (incl ACS)?
25-50mcg
every 5 mins
total max dose 5mcg/kg
84
What is the 18 - 75yrs PO dose of clopidogrel for cardiac reperfusion (PHT)?
300mg
single dose only
85
What is the 75yrs & older PO dose of clopidogrel for cardiac reperfusion (PHT)?
75mg
single dose only
86
What is the 18 - 75yrs IV dose of tenecteplase for cardiac reperfusion (PHT)?
Weight adjusted dose (refer to table) to a maximum of 50mg administered 15 minutes prior to the first dose of enoxaparin sodium
single dose only
87
What is the 75yrs & older IV dose of tenecteplase for cardiac reperfusion (PHT)?
Weight adjusted dose (refer to table) to a maximum of 50mg administered 15 minutes prior to the first dose of enoxaparin sodium
single dose only
88
What is the ≥18 - <75yrs IV enoxaparin first dose for cardiac reperfusion (PHT)?
30mg (0.3mL)
15 minutes after tenecteplase administration
Note:
Discard 30mg (0.3mL) and attach sodium chloride 0.9% primed microbore extension set prior to administering the remaining 30mg (0.3mL) IV as a bolus and flush with 30mL sodium chloride 0.9%.
89
What is the ≥18 - <75yrs SC enoxaparin second dose for cardiac reperfusion (PHT)?
Weight adjusted 1mg/kg (max dose of 100mg) administered 15 minutes after the 1st dose of enoxaparin sodium
90
What is the ≥75yrs SC enoxaparin dose for cardiac reperfusion (PHT)?
0.75mg/kg (max 75mg)
15 mins after tenecteplase
single dose only
91
What is the additional amount to be drawn up for the first dose only using a MAD?
0.1mL
92
What is the all ages IM dose of oxytocin for 3rd stage of labour?
10 IU
Single dose only
93
What is the all ages IM dose of oxytocin for PPH?
10 IU
Followed by infusion by ICP
94
What is the 6yrs of age and above (incl adults) IM/IV hydrocortisone dose for adrenal crisis?
100mg
Repeat once after 15 minutes
Total max dose 200mg
95
What is the 1 - 5 years of age IM/IV hydrocortisone dose for adrenal crisis?
50mg
Repeat once after 15 minutes
Max dose 100mg
96
What is the < 1 year of age IM/IV hydrocortisone dose for adrenal crisis?
25mg
Repeat once after 15 minutes
Total max dose 50mg
97
What is the all age IV dose of compound sodium lactate for dehydration?
10mL/kg bolus
single dose only
98
How much NaCl is used to flush the cannula before and after tenecteplase administration?
10ml before
30ml after
99
What is the 16yrs & older IV morphine dose for analgesia?
2.5-5mg
every 5 mins
total max dose 0.5mg/kg
100
What is the 16yrs & older IM/SC morphine dose for analgesia?
5-10mg
repeat once @ 15 mins
Max 2 doses
101
What is the 16yrs & older SC fentanyl dose for analgesia?
50-100mcg undiluted
repeated once @ 15 mins
Max 2 doses
102
What is the 16yrs & older IN fentanyl dose for analgesia?
50 -100 mcg undiluted
every 5 mins
no max dose
Note: remember to ad 0.1mL to initial dose for MAD dead space
103
What is the paediatric repeat dose regime for IN fentanyl?
every 10 mins
max dose 5mcg/kg
104
What is the 16yrs & older IV naloxone dose for opioid overdose?
100mcg diluted
every 2 mins
total max dose 2mg
105
What is the 16yrs & older IM naloxone dose for opioid overdose?
400mcg undiluted
every 2 mins
total max dose 2mg
106
What is the under 16yrs IM/IV/IO naloxone dose for etorphine or buproneorphine overdose?
10mcg/kg diluted
single max dose 2mg
every 5 min
no max dose
107
What is the 16yrs & older IM/IV naloxone dose for etorphine or buprenorphine overdose?
2mg undiluted
every 5 mins
no max dose
108
What is the under 16yrs IM/IV/IO naloxone dose for opioid overdose?
5mcg/kg diluted
single max dose 100mcg
every 2 mins
total max dose 2mg
109
What is the preparation of naloxone?
Ampoule
400mcg/1mL
Dilution: 400mcg (1mL) ampoule diluted to 4mL with 3mL NacL (100mcg:1mL)
110
What is the preparation of morphine?
ampoule
10mg/1mL
Dilution: 10mg (1mL) diluted with 9mL NaCl to a total volume of 10mL (1mg:1mL)
111
What is the preparation of fentanyl?
Ampoule
100mcg/2mL
Dilution: 100mcg (2mL) fentanyl diluted to 10mL with 8mL sodium chloride 0.9% (10mcg:1mL)
112
What is the 16yrs and over IM/IV adult hydrocortisone dose for anaphylaxis with persistent wheeze post salbutamol administration?
100mg reconstituted
Single dose only
Dilution: reconstitute with 2mL NaCl
113
What is the under 16yrs IM/IV paediatric hydrocortisone dose for anaphylaxis with persistent wheeze post salbutamol administration?
4mg/kg
single max dose 100mg
Single dose only
114
What is the 5yrs & older salbutamol NEB dose for anaphylaxis with bronchospasm?
5mg
Whilst indicated
No max dose
115
What is the under 5yrs salbutamol NEB dose for anaphylaxis with bronchospasm?
2.5mg
whilst indicated
No max dose
116
What are the preparations of salbutamol?
nebule
5mg/2.5mL
2.5mg/2.5mL
117
What is the all age IV/IO dose for medical hypoperfusion/hypovolaemia in moderate to severe anaphylaxis with signs of shock?
20mL/kg
whilst indicated
no max dose
118
What are the indications for olanzipine?
Behavioural disturbance
119
What are the contraindications for olanzipine?
Known hypersensitivity to olanzapine or to any other excipients in olanzapine ODTs (Mannitol, microcrystalline cellulose, carmellose calcium, sucralose, magnesium stearate, colloidal anhydrous silica).
120
What are the precautions for olanzapine?
* May cause respiratory depression or worsen depression associated with alcohol or benzodiazepine use
* May cause orthostatic hypotension; use cautiously in people whose condition may worsen if this occurs or in those with risk factors for hypotension, e.g. hypovolaemia, taking an anti-hypertensive.
* Pts with limited physiological reserves and the elderly have an increased risk of adverse effects.
* Used cautiously in patients who have a history of seizures or are subject to factors which may lower the seizure threshold.
* Effects on ability to drive and operate machines: Patients must be advised that olanzapine may cause drowsiness and may increase the effects of alcohol, cannabis or sleeping tablets. If affected, they do not drive or operate machinery.
121
What are the side effects of olanzipine?
Common (>1%) – sedation, dizziness, orthostatic hypotension, hyperglycaemia, peripheral oedema.
Infrequent (0.1 – <1%) – Extrapyramidal Side Effects (EPSE), elevation of liver aminotransferases.
Rare (<0.1%) – rhabdomyolysis, venous thromboembolism (VTE), hepatic failure, multi-organ hypersensitivity syndrome, QT prolongation.
122
What are the indications for droperidol?
Behavioural disturbance SAT score 2 or more
Palliative care
123
What are the contraindications for droperidol?
Allergy or hypersensitivity to droperidol.
Patients < 6 years of age.
Patients with Parkinson’s disease.
124
What are the precautions for droperidol?
* **May prolong QT interval**. Risk assessment and ECG monitoring is recommended in patients with cardiovascular disease or significant risk factors for cardiac arrhythmia. When used for severe behavioural disturbances, ECG is recommended once acute symptoms have resolved.
* May cause **mild to moderate hypotension**.
* **Use in the elderly**: The initial dose of droperidol should be reduced in the elderly, debilitated and other poor risk patients. The effect of the initial dose should be considered in determining incremental doses.
* **Effects on ability to drive and use machines**: Droperidol may impair mental and/or physical abilities for operating machinery or driving a motor vehicle. Patients must be advised to only drive or operate a machine if sufficient time has elapsed after the administration of droperidol, i.e. about 10 hours after a dose of up to 5 mg and 24 hours after higher doses.
125
What are the indications for ketamine?
Agitation in the trauma and critically ill patient
Analgesia
Behavioural disturbance
Cardiac arrest
126
What are the indications for midazolam?
* Agitation in the trauma and critically ill patient
* Behavioural disturbance
* Palliative care - Breathlessness
* Palliative care - restlessness and/or agitationSeizures
ICP only:
* Cardiac Arrest
* Distressing psychological reactions post ketamine administration
* Dysrhythmias
* Hypertensive disorders of pregnancy
* Limb realignment and/or difficult extrication
* Return of spontaneous circulation
127
What are the contraindications for midazolam?
Allergy or known hypersensitivity to benzodiazepines
128
What are the precautions for midazolam?
* **Consider** reduced doses in patients who have low body weight, respiratory disease, sleep apnoea, acute alcohol intoxication, shock and coma, myasthenia gravis, muscular dystrophies and myotonias
* Use in the **elderly** due to an increased risk of oversedation, ataxia, confusion, falls, respiratory depression, and short-term memory impairment; reduce dose and monitor closely
* Use in **renal impairment** – There is a greater likelihood of adverse drug reactions in patients with severe renal impairment
* Use in **hepatic impairment** – Hepatic impairment reduces the clearance of i.v. midazolam with a subsequent increase in terminal half-life. Therefore, the clinical effects may be stronger and prolonged. The required dose of midazolam may have to be reduced and proper monitoring of vital signs should be established
* Use in **pregnancy** (Category C) – Benzodiazepines should be avoided during pregnancy unless there is no safer alternative. Midazolam crosses the placenta and the administration of midazolam in the last weeks of pregnancy or at high doses during labour have resulted in neonatal CNS depression and can be expected to cause irregularities in the foetal heart rate, hypothermia, hypotonia, poor sucking and moderate respiratory depression due to the pharmacological action of the product
* Use in **lactation** - There is evidence that midazolam is excreted in breast milk and its effects on the newborn are not known
* **Effects on Ability to Drive and Use Machines** - Patients should be warned to take extra care as a pedestrian and not to drive a vehicle or operate a machine until the patient has completely recovered from the effects of the drug, such as drowsiness. The physician should decide when activities such as driving a vehicle or operating a machine may be resumed. The patients’ attendants should be made aware that the patients’ anterograde amnesia may persist longer than the sedation and therefore, patients may not carry out instructions even though they appear to acknowledge them. If sleep duration is insufficient or alcohol is consumed, the likelihood of impaired alertness may be increased
129
What are the side effects of midazolam?
* Common (>1%) – hypotension, hiccup, cough.
* Infrequent (0.1 – <1%) – pain on injection, erythema at injection site, rash, laryngospasm, bronchospasm, nausea, vomiting, headache, confusion, restlessness.
* Rare (<0.1%) – arrhythmias, cardiorespiratory arrest, anaphylactic/anaphylactoid reactions.
130
What are the indications for fentanyl?
Agitation in the trauma and critically ill patient
Analgesia
131
What are the contraindications for fentanyl?
* Epistaxis or occluded nasal passages (IN route)
* Previous or known allergy or adverse reaction
* Pregnant women ≥ 20 weeks gestation in labour
132
What are the side effects of fentanyl?
* Common (>1%): rash, bradycardia; may have a lower incidence of nausea, vomiting and constipation than other opioids
* Rare (<0.1%): chest wall rigidity with rapid/very high IV doses
133
What are the precautions for fentanyl?
**Pregnant women ≥ 20 weeks**.
**Bradyarrhythmias** - may be exacerbated.
**MAOIs** - Fentanyl should be administered with caution for patients who are receiving or have received treatment within 14 days, with an MAOI due to the risk of serotonin toxicity (fentanyl can contribute to serotonin toxicity). Where an alternate analgesic agent (e.g. morphine) is available it should be used.
**Respiratory depression** - Use opioids with extreme caution in patients with respiratory depression, severe obstructive airways disease, at risk of upper airways obstruction (e.g. sleep apnoea), asthma or decreased respiratory reserve as they may depress respiration, decrease the cough reflex and dry secretions.
**Newborns** - Opioid analgesics may cause respiratory depression in the newborn, withdrawal effects may occur in neonates of dependent mothers.
**Effects on ability to drive and use machines** - Fentanyl may cause drowsiness and general impairment of co-ordination and may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks, such as driving a car or operating machinery. Ambulatory patients should be cautioned against driving or operating machinery. Patients should only drive or operate a machine if sufficient time has elapsed (at least 24 hours) after the administration of fentanyl.
134
What are the indications for glucagon?
* Anaphylaxis and Allergic Reactions
* Hypoglycaemia
135
What are the contraindications for glucagon?
nil
136
What are the indications for salbutamol?
* Asthma
* COPD Exacerbation
* Anaphylaxis & Allergic Reactions
* Palliative Care
137
What are the contraindications for salbutamol?
Nil
138
What are the indications for ipratropium bromide?
* asthma
* chronic obstructive pulminary disease (COPD)
139
What are the contraindications for ipratropium bromide?
* Pts < 6 months of age
* Allergy or hypersensitivity to ipratropium bromide
* Glaucoma
140
Where does the T Piece go when administering nebulised medication with a mask and bvm?
between the mask and filter (filter attached to bvm)
141
What are the indications for CPAP?
* basal crackles - if nil response to oxygen and GTN +/- frusemide
* mid zone to full field crackles - concurrently with pharmacology
142
What are the contraindications for CPAP?
* Pt does not consent
* LOC = P or U
* facial trauma
* epistaxis
* pneumothorax
* hypoventilation
* vomiting
* SBP <90mmHg
* Pt removes consent/does not tolerate CPAP
143
What are the indications for glucose 10%?
* hypoglycaemia
* newborn resuscitation
144
What are the contraindications for glucose 10%?
Nil
145
What are the indications for glucose gel?
hypoglycaemia
146
What are the contraindications for glucose gel?
* ↓ LOC
* altered gag reflex
147
What are the indications for midazolam?
* Seizures
* Agitation in the trauma and the critically ill patient
* Behavioural disturbance
* Hypertensive disorders of pregnancy
* Palliative Care
148
What are the contraindications for midazolam?
Allergy or known hypersensitivity to benzodiazepines
149
Compound sodium lactate note for anaphylaxis cardiac arrest.
If the patient deteriorates into cardiac arrest a further bolus of compound sodium lactate should be administered irrespective of previous administration.
150
What are the indications for aspirin?
ACS
151
What are the contraindications for aspirin?
* allergy or hypersensitivity
* active, suspected or known bleeding tendency
* Pts <16 yrs
* T1 trauma criteria
152
What are the indications for GTN?
* Acute Coronary Syndrome (ACS)
* Cardiogenic Pulmonary Oedema (CPO)
* Autonomic dysreflexia
153
What are the contraindications for GTN?
* BP < 90mmHg systolic
* Pulse rate < 50/min or > 150/min
* Patients < 16 years of age
* Viagra type drugs:
* Sildenafil (Viagra®) or Vardenafil (Levitra®) within 24 hours
* Tadalafil (Cialis®) within 96 hours
154
What are the indications for fentanyl?
* Agitation in the trauma and critically ill patient
* Analgesia
155
What are the contraindications of fentanyl?
* Epistaxis or occluded nasal passages (IN route)
* Previous or known allergy or adverse reaction
* Pregnant women ≥ 20 weeks gestation in labour
156
What are the indications for clopidogrel?
Cardiac Reperfusion - Prehospital Thrombolysis
157
What are the contraindications for clopidogrel?
* Allergy or hypersensitivity to clopidogrel
* Active, suspected or known bleeding tendency
* Patients < 18 years of age
* Pregnancy or breast feeding
* Any exclusion via Prehospital Thrombolysis Checklist
158
What are the indications of tenecteplase?
Cardiac reperfusion - Prehospital Thrombolysis (PHT)
159
What are the contraindications of tenecteplase?
* Patients <18 years of age
* Any exclusion via Prehospital Thrombolysis Checklist
160
What are the indications for enoxaparin?
Cardiac Reperfusion - Prehospital Thrombolysis
161
What are the contraindications for enoxaparin?
* Allergy or hypersensitivity to enoxaparin sodium
* Any exclusion per Prehospital Thrombolysis Checklist
162
What are the indications for naloxone?
Opioid overdose
163
What are the contraindications for naloxone?
Neonates born to opioid addicted mothers due to risk of inducing opioid withdrawal
164
What are the side effects of naloxone?
* Opioid withdrawal (nausea, vomiting, sweating, tachycardia, hypertension & combative behaviour)
* Pulmonary Oedema in patients with pre-existing cardiac disease
* Dysrhythmias (VF,VT)
165
What are the side effects of salbutamol?
dysrhythmias (in large doses)
shaking and trembling
166
What are the side effects of glucagon?
nausea & vomiting
allergic reactions (rarely)
167
Why should caution be used when flushing medications in patients < 16 years of age?
as excessive volume administration may inadvertently occur
168
What is the mechanism of action of olanzapine?
antagonises serotonin (5HT2A/2C, 5HT3, 5HT6), dopamine (D1, D2, D3, D4, D5) and cholinergic muscarinic receptors
169
What type of drug is olanzapine?
atypical antipsychotic, anti-manic and mood stabilising agent
170
What type of drug is droperidol?
Antipsychotic
171
What is the mechanism of action of droperidol?
Competitively blocks D2 receptors in the mesolimbic system causing an increased turnover of brain dopamine to produce antipsychotic effect
* Potent D2 (dopamine receptor) antagonist with some histamine and serotonin antagonist activity.
* Competitively blocks D2 receptors in the mesolimbic system causing an increased turnover of brain dopamine to produce an antipsychotic effect.
* Causes Central Nervous System (CNS) depression at subcortical levels of the brain, midbrain, and brainstem reticular formation.
* Antiemetic effect occurs by acting via D2 receptors in the stomach and Chemoreceptor Trigger Zones (CTZ).
* The blood pressure is lowered, in part as a direct vasodilator effect and in part because of adrenergic blockade.
Mesolimbic system is a CNS circuit
172
What drugs does droperidol interact with?
* May increase the action of sedatives and opiates
* May increase the action of anti-hypertensive agents and orthostatic hypotension may occur.
173
What drugs does olanzapine interact with?
Sedatives/alcohol: Over sedation due to synergistic effects. Avoid combination where possible.
174
What type of drug is ketamine?
anaesthetic agent
175
What is the mechanism of action of ketamine?
* Antagonises N-methyl-D-aspartate (NMDA) receptors
* interacts with muscarinic receptors, descending monoaminergic pain pathways, voltage-sensitive calcium channels and opioid receptors in brain and spinal cord
176
What are the interactions of ketamine?
* Other central nervous system (CNS) depressants (e.g. ethanol) can potentiate CNS depression and/or increased risk of developing respiratory depression.
* Benzodiazepines may prolong the half-life of ketamine.
177
What type of drug is midazolam?
benzodiazepine
178
What are the interactions of midazolam?
Concomitant use of barbiturates, alcohol or other central nervous system depressants
These increase the risk of underventilation or apnoea and/or cardio-ventricular depression and may contribute to a profound and/or prolonged drug effect, that could result in coma or death.
179
What is the mechanism of action of midazolam?
Enhanbces the action of the inhibitory neurotransmitter GABA across all levels of the CNS
180
What type of drug is fentanyl?
a pure opioid agonist
181
What is the mechanism of action of fentanyl?
Acts primarily on mu-opioid receptors in the brain, spinal cord and smooth muscle.
* Produces analgesia, anxiolysis, respiratory depression, sedation and constipation.
* Secondary actions include increase in the tone and decrease in the contractions of the gastrointestinal smooth muscle, which results in prolongation of gastrointestinal transit time and may be responsible for the constipatory effect of opioids.
* All opioid mu-receptor agonists, including fentanyl, produce dose dependent respiratory depression. The risk of respiratory depression is less in patients with pain and those receiving chronic opioid therapy who develop tolerance to respiratory depression and other opioid effects.
182
What are the interactions with fentanyl?
Use with caution and consider reduced dosages when using concurrently with patients receiving other central nervous system depressants (including alcohol), due to the risk of profound sedation, respiratory depression and hypotension.
183
What type of drug is fentanyl?
Synthetic narcotic analgesic (opioid)
184
What is the mechanism of action of fentanyl?
Binds to opioid receptors (mainly mu-opioid) in the CNS and GIT reducing the transmission of pain impulses and modulates the descending inhibitory pathways from the brain.
185
What type of drug is morphine?
narcotic analgesic
186
What is the mechanism of action of morphine?
Binds to opioid receptors (mainly mu-opioid) in the CNS and GIT reducing the transmission of pain impulses and modulates the descending inhibitory pathways from the brain.
187
What type of drug is naloxone?
opioid antagonist
188
What is the mechanism of action of naloxone?
antagonises the opioid effects by competing for the same receptor sites
189
What type of drug is salbutamol?
sympathomimetic
190
What is the mechanism of action of salbutamol?
stimulates B2 receptors in bronchial smooth muscle resulting in bronchodilation
191
What type of drug is glucagon?
pancreatic hormone
192
What is the mechanism of action of glucagon?
converts liver glycogen to glucose
193
What are the signs and symptoms of mild/moderate asthma?
* Can walk, speak whole sentences in one breath (for young children can move around and speak in phrases)
* SpO2% > 94% room air
* Pulse rate < 100/min Adult and Paed
* PEFR >75% of predicted Adult and > 60% Paed of predicted or best (if known) or cannot be performed
194
What are the signs and symptoms of severe asthma?
* Unable to complete sentences in one breath due to dyspnoea
* SpO2% 90-94% room air
* Pulse rate 100-120/min Adult and 100-200/min Paed
* Accessory muscle use or ‘tracheal tug’ during inspiration or subcostal recession (abdominal breathing)
* Obvious respiratory distress
* PEFR 50-75% Adult and 40-60% Paed of predicted or best (if known) or cannot be performed
195
What are the signs and symptoms of life-threatening asthma?
* Talks in words
* SpO2% <90% room air
* Pulse rate > 120/min Adult and > 200/min Paed (bradycardia present when respiratory arrest is imminent)
* Poor respiratory effort, soft/absent breath sounds
* Reduced consciousness or collapse
* Exhaustion/agitation
* Cyanosis
* PEFR <50% Adult and < 40% Paed of predicted or best (if known) or cannot be performed
196
What are the signs and symptoms of anayphylaxis?
Any ONE or MORE of the following:
* Persistent dizziness or collapse
* Pale and floppy (young children)
* Swelling of the tongue
* Swelling/tightness in the throat
* Difficulty talking/hoarse voice
* Difficult/noisy breathing
* Wheeze or persistent cough
* Persistent abdo pain and vomiting after exposure to a likely allergen (including injected medications and insect bites/stings)
197
What are the signs and symptoms of mild to moderate allergic reaction?
* Swelling of lips, face, eyes
* Tingling mouth
* Hives or welts
* Transient, resolving or active vomiting
* Abdominal pain
If in doubt treat as anaphylaxis
198
What are the signs and symptoms of anayphylaxis?
Any ONE or MORE of the following:
* Persistent dizziness or collapse
* Pale and floppy (young children)
* Swelling of the tongue
* Swelling/tightness in the throat
* Difficulty talking/hoarse voice
* Difficult/noisy breathing
* Wheeze or persistent cough
* Persistent abdo pain and vomiting after exposure to a likely allergen (including injected medications and insect bites/stings)
NSW Ambulance
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