London anbulance service Unofficial .Drug Protocols

Indications
Any conscious adult who is suspected of having an acute coronary syndrome and who presents with any or all of the following;
severe chest pain for more than 15 mins
Severe pressure in the chest for more than 15 mins
Severe tightness in the chest for more than 15 mins
Contraindications
Known allergy to aspirin

Caution
Pregnancy
Side effects
None at dosage given
Presentation
Foil wrapped 300mg oral Aspirin tablet
Administration and dosage
ONE 300 mg oral aspirin Chewed. Maximum dosage 300mg

Indications
Sinus bradycardia. When accompanied by symptomatic hypotention.Pulse rate <50 Systolic <90 mmHg
Junctional rhythm. With pulse rate < 50. Systolic bp < 90
2nd, 3rd degree heart block. with heart rate < 50 Systolic Bp < 90 mmHg.
Asystole. As per asystole protocol.

Prior to administration patients with a pulse an ECG print out is required to confirm indicating rhythm where possible. except in Asysole, PEA less than 60 and organophosphate poisoning
Contraindications
Atrial flutter or atrial fibrillation where there is a rapid ventricular response.

Should not be used to treat bradycardia in hypothermia.
Glaucoma
Side Effects
Blurred vision,Dry mouth,Thirst,Flushing skin,Confusion, increased body surface temperature.
Presentation
Prefilled syringe 1mg/10ml
Prefilled syringe 3mg/10ml
Administration and dosage
Symptomatic bradycardias
0.5mg/5ml IV. repeat once after 5-10 mins if necessary.
Asystole or PEA
3mg IV once as per asystole protocol
6mg ET once as per asysole protocol
Post arrest patients who have received atropine must not receive further doses.

2mg IV( IM if IV route is not available) repeated every 20 -30 mins untill becomes flushed and dry,pupils dilate and tachycardia develops.

Children under 14. most common cause is hypoxia requiring immediate ABC care and not drug therapy.

Indications Prolonged convulsions from whatever cause in adults and children over six.
Status epilepticus.
Eclampsia.
Contraindications
None in the above context. It should be noted that if other CNS depressants are involved e.g. alcohol the patient is more likely to develop respiratory depression.
Side effects
Drowsiness, Respiratory depression, Coma.
Presentation
Ampoule. 10mg diazepam/2ml (5mg/ml).
Administration and dosage
Adults and children over six
2.5mg (0.5ml) IV every 30 seconds until fitting controlled to a maximum of 10mg (2ml).
Repeat once after five mins if necessary.
Maximum dose 20mg.
Rectal stesolid
Presentation.
Pre-packed tube with introducer. 5mg and 2.5mg
Administration and dosage
Adults and children over 6 years. 5mg rectally every minute until fitting controlled. maximum dosage 20mg
Children over 3 to 6 years. see above
Children over 1 to 3 years. 5mg rectally. Repeat once after 5 mins if necessary to a maximum of 10mg
Children 0 to 1 year. 2.5 rectally. Repeat once if necessary to a maximum of 5mg

Indications
In cardiac arrest with the following presenting rhythms;
VF and pulsless VT
Asystole
PEA (EMD).
contraindications
None in cardiac arrest
Presentation
prefilled syringe 1mg .
Administration and dosage
1mg IV, 2mg ET as per arrest protocol.

EPINEPHRINE 1:1,000 P
Indications
Paediatric advanced life support see ETO 5.
Anaphylaxis where the patient presents with dyspnoea, rapid pulse >100bpm, Progressive hypotension.
Contraindications
None as regard to the above
Presentation
Ampoule 500mcg 1:1,000 in 0.5mls.
Ampoule 10mg 1:1,000 in 10mls.
Administration and dosage.
Paediatrics ALS refer to ETO 5
Patients over 10 years 1mg/1ml
Patients between 5-10 years 250mcg/0.25ml
Patients between 2-4 years 125mcg/0.125ml

Patients suffering Left Ventricular failure is often characterised by a history of cardiac problems, shortness of breath, often with accompanying dyspnoea, tachycardia, cyanosis, crackles and wheezes and often foamy blood tinged sputum. Due to impaired oxygenation the patient can also be very anxious and agitated. Oxygen must be considered before administration of drug therapy.

IV Injection slowly over 1minute (preferred route). When administering IV the frusemide is to be mixed with saline flush (total fluid including drug=10mls) in 10ml syringe.

Indications
Cardiac chest pain due to ; Angina pectoris or MI without related hypotension
Contraindications
MI with related hypotension . Actual or estimated
Head trauma

Cerebral haemorrage
Patients who have taken viagra ( Sildenafil ) within the previous 24 hrs.
Side effects
Headaches
Dizziness
Weakness
Hypotension
Presentation
Aerosol spray giving a metered dose of 400mcg
Administration and dosage
800mcg sublingually

Indications
Known diabetic patients on insulin therapy where symptomatic hypoglycemia has been confirmed by a BM test reading of 4mmols or below.
Unconscious patient without known cause where a BM test of 4 mmols or below has been confirmed.
Contraindications
None as regard to the above.
Side effects
None
Presentation
1ml syringe prefilled with water and vial containing 1mg of glcagon powder
1ml vial of glucagon powder and 1ml bottle of sterile water.
Administration and dosage
Patients age 13 years and over 1mg in1ml
Patients age under 13years 0.5mg in 0.5mls.
Routes; IM,IV,Subcut.

Hypoglycemia in the Conscious patient. The signs and symptoms exhibited may include the following. Known history of hypo attacks, Weakness and lightheadedness, Fatigue, confusion, sweating, slurred speech ataxia, Irritable and bizarre behaviour, falling levels of consciousness, falling blood sugar level.

Pack of three single dose bottles. Each bottle contains 9.2g of dextrose 40% as the active ingredient.

Ensure patient is conscious and able to swallow.Max dose 2 bottles (18.4)g). Administer O2.Take and record blood sugar level. If <4mmols consider Glucagon.

Squeeze small amount into patients mouth and gently massage into buccal cavity. Repeat until patient responds to treatment

Indications
Patients over the age of 12 years presenting with ventricular tachycardia with a palpable pulse greater than 140bpm.
Contraindications
Known history of allergy to lignocane or local anaesthetics.
Side effects
Hypotension,drowsiness, confusion, numbness and seizures in high doses
Presentation
Prefilled syringe 100mg/5ml.
Administraton and dosage
VT. 100mg slowly over 1 minute.Repeat once after 15 mins if VT is not controlled.
Maximum cumulative dosage 200mg IV

Prior to administration patients with a pulse an ECG print out is required to confirm indicating rhythm where possible.

metaclopramide is an anti-emetic whose action is closely associated with parasympathetic nervous control of the upper gastro-intestinal tract.

Sever extra pyramidal effect (tremor and rigidity of voluntary muscles. In extreme cases the patient may also be stiff in their walking, hand co-ordination, swallowing and speaking is impaired ), more commonly in children and young adults.

When administering prior to the use of tramadol, the cannula must be flushed with normal saline following administration and a different syringe used to administer tramadol.

Note. BP, pulse, resps, cardiac rhythm must be monitored during and after administration

Indications
Patients aged over 1 year who are suffering moderate to severe pain caused by illness, trauma or ischemic type chest pain, where the pain is not relieved by entonox, or where entonox is inappropriate.
Contraindications
Known allergy to nubain.Strong history of allergy to medication.
Pregnancy and childbirth, where this is the primary presenting condition. If pain due to illness, trauma or ischaemic type chest pain seek medical advice via CAC.
Head injuries with a GCS of 14 or less.

Evidence of impaired respiratory function
Patients already been administered strong analgesic.
Patients taking Monoamine oxide inhibitors. MAOI's
Cautions
Patients with a systolic BP of 90 or less, and those with a pulse rate of 50 or below.
Patients that are taking psychiatric medication other than MAOI'S as contraindicated above.

Chest injuries with accompanied DIB.
Side effects
Drowsiness, dizziness, dry mouth, Respiratory depression in large doses, nausea and vomiting.
Presentation
Ampoule 10mg in 1ml.
Administration and dosage
Ensure that 800mcg of naloxone is available in case of respiratory depression.
Patients over 12 years10mg IV slowly over 1-2 mins. using 1ml syringe. wait 5-10 mins and repeat if required.
Maximum dose 20mg.

Patients aged 1-12 . 300mcg per kilogram of body weight IV slowly over 1-2 minutes

Indications
Known narcotic overdose or coma suspected to be due to narcotic overdose
Respiratory depression as a result of overdose of Co-Proximol.
Respiratory depression as a result of administration of nubain.
Contraindications
None
Side effects
Rapid administration may lead to projectile vomiting and ventricular dysrhthmias.
Rapid administration may lead to projectile vomiting and ventricula dysrhthmias.
Administration to people who are physically dependant on narcotics may cause an acute withdrawal syndrome.
In general the action of naloxone is shorter than that of the narcotic which it is reversing, thus the patient may fall back into a stupor or coma as the naloxone wears off. These patients must therefore be closely observed and the dose repeated if necessary.
Presentation
Pre-filled syringe 800mcg/2ml
Administration and dosage.
Over 6-adult 1st dose 800mcg .2nd dose 800mcg after 5mins .3rd dose 800mcg after 15mins.
Routes in order in cardiac arrest IM, IV, ET. General route I.M.
1 to six years 1st dose 200mcg. 2nd dose 400mcg after 5mins. 3rd dose 800mcg after 15mins. Routes in cardiac arrest in order IM, IV, IO.General route IM.
Under 1 year. 1st dose 100mcg. 2nd dose 200mcg after 5mins. 3rd dose 400mcg after 15mins.
Routes in order in cardiac arrest IM. General route IM.

Indications
acute asthma attack or acute severe asthma attack
Acute bronchospasm
Contraindications
acute myocardial ischaema
Presentation
2.5 mg nebule
Administration and dosage
Patients over 5 years 5mg nebulised. second and subsequent dosages may be given on route to hospital if the patients condition does not improve
Patients 0-5 years. 2.5 mg nebulised plus subsequent doses as above.

Indications
Haemorrhage occurring within 24 hours of childbirth (post partum) where the bleeding is uncontrolled despite the application of uterine massage.
Contraindications
Never give syntometerine if the baby is still in the uterus. Be aware of the potential of the presence of a second or subsequent babies still to be delivered.The potential for an undiagnosed twin is higher in those women who have not sought ante-natal care/assessment.
Side effects
Nausea
Headaches
Abdominal pains
Palpitations
Bradycardia
Transient hypertension
Presentation
500mcg of ergometrine maleate plus 5 units of oxytocin in a 1ml ampoule.
Administration and dosage
500mcg IM once only
500mcg IV once only. IV access should only be used if IV access was gained before the post partum haemorrhage occurred.

Is a synthetic opioid analgesic chemically similar to natural opiods.I acts upon the central nervous system by inhibiting the re-uptake of serotonin and noradranaline, which are released by the brain in response to painfil stimuli. It also binds to the CNS mu-opiod receptor sites and so may, in theory cause respiratory depression. The analgesic effects of tramadol wear off after approximately 4 hours.

patients on monoamine oxide inhibitors (MAOI's e.g Malpan, Nardil, Parnate, Parstelin ) or having taken them in the previous two weeks.

Transient nausea may occour following administration. Therefore Metoclopromide 10mg IV must be given to patients over 20 Years of age Prior to the administration of tramadol. The cannula must be flushed with normal saline and a different syringe used to administer tramadol.

convulsions may be caused by too rapid intravenous infusion, especially in epileptics. Each bolus should be given slowly over 2-3 minutes

Initial dose of 50mg ( 5ml diluted saline) IV slowly over 2-3 minutes. A further 50mg dose may be given following reassesSment after 2-5 mins. Further boluses may be given after 15 mins. Maximum cumulative dose of 200mg (20mls dilued)

Please check your own protocols as these are being continually changed and updated .

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