Emergency drugs in general practice

[Pages:6]clinical practice

Andrew Baird MA, MBChB, DRANZCOG, DA, FRACGP, FACRRM, is a general practitioner, Brighton, Victoria. bairdak@

Emergency drugs in general practice

This review article discusses available drugs for the initial management of medical emergencies in general practice.

Table 1. General principles in the management of medical emergencies

? Danger, response, airway, breathing, circulation (and compressions) ? DRABC

? A ctivate a crisis resource management plan ? get help (eg. other practice staff, ambulance professionals via `000', bystanders) ? assign roles (including leader, scribe, and timekeeper) ? facilitate teamwork

? Some history is better than no history ? any drugs or allergies? ? any `not for resuscitation orders'? (Ideally sighted, and on standardised forms) ? if available ? ask relatives, check medical records

? Give oxygen (8 L/min) via Hudson mask (via bag-valve-mask system in cardiac arrest)

? Intravenous drugs are generally given over 2?5 minutes (but as a `push' with saline flush in cardiac arrest)

? Continuous assessment and management until stable ? Observe patient once stable (especially if sedative drugs

have been administered) ? Be willing to consult with an emergency department for

advice and patient transfer ? Practise safe sharps management, and follow infection

control procedures ? Take detailed notes, and transcribe these to the patient's

medical record at the earliest opportunity. Keep copies of any transfer of care letters ? Arrange debriefing as appropriate for the patient (or relatives), and for those involved in managing the emergency

General practitioners need the knowledge, skills, drugs and equipment for managing medical emergencies. Clinics need treatment rooms and doctor's bags that enable emergencies to be managed onsite and offsite respectively. Rural medical generalists may provide more advanced emergency management in their local hospitals. In managing emergencies, GPs may be working with paramedics, therefore it helps to be familiar with their skills and with the drugs they carry. General principles that apply in managing medical emergencies are described in Table 1. Relevant contraindications should be checked before administering any of the drugs described below (Table 2).

Life threatening medical emergencies

Cardiac arrest Current guidelines1 emphasise the importance of cardiac compressions, and prompt defibrillation for ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Adrenaline is given every 3 minutes intravenously (IV) until return of spontaneous circulation (ROSC): ? adult dosage: 1 mg with a saline flush (10?20 mL) ? p aediatric dosage: 0.01 mg/kg (10 ?g/kg) (Table 3) with a saline flush (up

to 5 mL). During cardiopulmonary resuscitation, the following drugs may be considered: ? VF or VT: lignocaine 1 mg/kg ? asystole or severe bradycardia: atropine 1.2?3.0 mg (adult);

20 ?g/kg (child) In the hospital setting amiodarone is the first line drug for treating ventricular arrhythmias. Following ROSC, blood pressure (BP) and adequate perfusion should be maintained. This may require IV adrenaline (Table 4).

Anaphylaxis2

? Adrenaline is given every 5 minutes intramuscularly (IM) (anterolateral thigh) until clinical features have improved. Up to 10 doses may be given: ? adult dosage: 0.5 mg ? paediatric dosage: 0.01 mg/kg (10 ?g/kg) (Table 3) ? in adults, if there is a poor response, consider glucagon 1?2 mg IV over 5 minutes ? c onsider IV adrenaline if shock persists after two IM doses; use with extreme caution (Table 4)

Reprinted from Australian Family Physician Vol. 37, No. 7, July 2008 541

clinical practice Emergency drugs in general practice

? Oxygen (8 L/min) ? Normal saline (20 mL/kg) is given for hypotension ? Hydrocortisone 250 mg (or 4 mg/kg), single dose IV.

Potentially life threatening emergencies

Asthma and bronchospasm3 Critical or severe (any of: talking in words, unable to talk, SpO2 94% ? nebulised salbutamol 10 mg driven by oxygen, at least 8 L/min every

15 minutes ? nebulised ipratropium 500 ?g 2 hourly ? hydrocortisone 250 mg (or 4 mg/kg) IV

Paediatric: ? oxygen at least 8 L/min to maintain SpO2 >94% ? nebulised salbutamol (5 mg/2.5 mL) driven by oxygen, at least 8 L/min,

continuous

? ipratropium 20 ?g/dose metered dose inhaler (MDI) via spacer, 2?4 puffs every 20 minutes in first hour

? hydrocortisone 4 mg/kg IV. If there is no response to inhaled salbutamol, then salbutamol should be given IV as a bolus (250 ?g for adults, 5 ?g/kg over 10 minutes for children) followed by an infusion. This may not be practical in most general practice settings. Consider IV adrenaline in extremis (Table 4).

Mild/moderate

Adult: ? oxygen at least 8L/min to maintain SpO2 >94% ? salbutamol 100 ?g/dose MDI via spacer, 10?20 puffs (4?6 tidal

breaths per puff) every 1?4 hours, or salbutamol 5?10 mg nebulised, driven by oxygen every 1?4 hours ? ipratropium 20 ?g/dose MDI via spacer, six puffs every 2 hours, OR ipratropium 500 ?g nebulised, driven by oxygen every 2 hours (ipratropium is optional) ? prednisolone 50 mg orally

Table 2. Emergency drugs: presentation, contraindications, and potential adverse reactions (in emergency use)

Drug presentation Adrenaline: 1 mg/1 mL (1:1000) Atropine: 600 ?g/1 mL ADT: 0.5 mL vial

Benztropine: 2 mg/2 mL Benzylpenicillin powder: 600 mg or 3 g Dexamethasone: 4 mg/1 mL Diazepam: 10 mg/2 mL

Dihydroergotamine: 1 mg/1 mL

Frusemide: 20 mg/2 mL Glucagon: 1 mg/1 mL GTN spray: 400 ?g/dose

Haloperidol: 5 mg/1 mL

Hydrocortisone: 100 mg or 250 mg/2 mL Lignocaine: 100 mg/5 mL Metoclopramide: 10 mg/2 mL

Morphine sulphate: 15 mg or 30 mg/1 mL Naloxone Min-I-Jet: 0.8 mg/2.0 mL or 2 mg/5 mL Prochlorperazine: 12.5 mg in 1.0 mL

Contraindications (other than known allergy) Nil in cardiac arrest and anaphylaxis

Nil in cardiac arrest or hypotensive bradycardia Children ................
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