OHFP.indb 212 OHFP.indb 212 30/05/2014 16:18 30/05/2014 16:18 213 pharmacopeia Potassium oral supplement potassium salt Dose potassium chloride: 2 \200\2234g/24h PO (two tablets/8 \200\22312h) Indication potassium loss CI serum potassium >5mmol/l Caution renal impairment, elderly, intestinal strictures, history of peptic ulcer SE GI disturbance, uppe r GI ulceration Info check serum Mg2+ as this is also likely to be low in dK+ BNF 9.2.1.1. Pravastatin HMG CoA reductase inhibitor see statin. Prednisolone corticosteroid Dose initially: 10 \200\22320mg/24h mane PO though often 30 \200\22340mg/24 PO in severe disease (up to 60mg/24h); maintenance: 2.5 \200\22315mg/24h PO Indication suppression of infl amma- tory and allergic disorders (eg IBD, asthma, COPD), i mmunosuppres- sion CI systemic infection without antibiotic cover Caution adrenal suppressi on SE peptic ulceration, Cushing \200\231s syndrome, DM, osteo- porosis Interaction duratio n of action decreased by rifampicin, car- bamazepine, phenytoin; duration of action increas ed by erythromycin, ketoconazole, ciclosporin Info consider bone and GI protection strate- gies when using long-term corticosteroids; see b p177 BNF 6.3.2. Pregabalin antiepileptic D ose epilepsy: 25mg/12h PO increased every 7d by 50mg to 100 \200\223150mg/8 \200\22312h (ma x 600mg/24h in divided doses) pain/anxiety: 75mg/12h increased every 3 \200\2237d up to max 600mg/24h in divided doses Indication epilepsy, neuropathic pain, generalized anxiety diso rder CI pregnancy, breastfeeding Caution renal impairment, severe congestive heart failure, avoid abrupt withdrawal SE GI disturbance, dry mouth, dizziness, drowsiness BNF 4.8.1. Prochlorperazine phenothiazine see antiemetics. Procyclidine anticholinergic Dose 2.5mg/8h PO increased every 3d up to max 30mg/24h in divi ded doses; acute dystonia: 5 \200\22310mg IM/ IV Indication parkinsonism; drug-induced extr apyramidal symptoms CI urinary retention, glaucoma, myasthenia gravis Caution pregnancy, br eastfeeding, hepatic or renal impairment, cardiovascular disease, pros- tatic hyperplasia, tardive dyskinesia SE antimuscarinic eff ects BNF 4.9.2. Propranolol see beta-blockers. Protamine heparin antagonist Dose 1mg IV neutralizes 80 \200\223100units heparin IV in last 15min (max 50mg at rate <5mg/min); 1mg IV neutralizes 100units heparin SC (max 50mg at rat e <5mg/min) Indication heparin OD, bleeding in patient on heparin therapy Caution risk of a llergy increased post-vasectomy, or in infertile men, fi sh allergy SE GI disturbance, fl u shing, hypotension, dyspnoea Info Protamine can also be used to help reverse the eff ects o f LMWH but it is much less eff ective at this than for heparin BNF 2.8.3. Prozac selectiv e serotonin re-uptake inhibitor see fl uoxetine. Pulmicort corticosteroid see budesonide. _OHFP.indb 213 _OHFP.indb 213 30/05/2014 16:18 30/05/2014 16:18 214 CHAPTER 5 Pharmacopeia Quinine plant alkaloid Dose nocturnal leg cramps 200 \200\223300mg/24h (nocte) PO; treatmen t of malaria see BNF 5.4.1 Indication nocturnal leg cramps, treatment and prophylaxis of ma laria CI haemoglobinuria, myasthenia gravis, optic neuritis, tinnitus Caution pregnancy (te ra- togenic in 1st trimester), breastfeeding, hepatic or renal impairment, cardiac disease (AF, conduction defects, heart block), elderly, G6PD defi ciency SE cinchonism (tinnitus, h eadache, hot and fl ushed skin, nausea, abdominal pain, rashes, visual disturbances (includ ing temporary blindness), confusion), acute renal failure, photosensitivity BNF 5.4.1 and 1 0.2.2. Ramipril see ACEi. Ranitidine antihistamine (H2-antagonist) Dose 150mg/12h PO; IV preparati on available (see BNF) Indication peptic ulcers, GORD Caution pregnancy, breastfeeding, ren al impairment, acute porphyria, may mask symptoms of gastric cancer SE GI upset, confusion, fatigue BNF 1.3.1. Reteplase plasminogen activator see fi brinolytic. Rifampicin antibiotic Dose tuberculosis: consult BNF; meningitis prophylaxis: 600mg/12h PO for 2d; other serious infections: 600mg/12h IV (usually after microbiology advice) Indicati on tuberculosis, N. meningitidis/H. infl uenza meningitis prophylaxis, serious staphylococc al infections CI jaundice Caution pregnancy, hepatic or renal impairment, alcohol dependenc e, acute porphyria SE GI disturbance, headache, drowsiness, hepatotoxicity, turns body secr etions orange Interaction induces p450, decreases eff ects of warfarin BNF 5.1.9. Rosuvastatin HMG CoA reductase inhibitor see statin. (r)tPA plasminogen activator see fi brinolytic. Salbutamol B2 agonist Dose airways disease 100 \200\223200micrograms aerosol/200 \200\223400micrograms powder INH PRN (max 400 \200 \223800micrograms/24h in divided doses); 2.5 \200\2235mg/4h NEB; status asthmaticus 2.5 \200\2235mg/PRN NEB; 250micrograms/STAT (diluted to 50micrograms/ml) slow IV, followed by m aintenance infusion of 3 \200\22320micrograms/min (3 \200\22324ml/h of the 50micrograms/ml solution), titrated to heart-rate Indication asthma; chronic and acute, other reversible ai rway obstruction eg COPD, iK+ Caution cardiovascular disease, DM, hyperthyroidism SE fi ne tremor, nervous tension, head- ache, palpitation, muscle cramps BNF 3.1.1.1. Salmeterol lon g-acting B2 agonist Dose 50 \200\223100micrograms/12h INH Indication chronic asthma, revers ible airway obstruction Caution cardiovascular disease, DM, hyperthyroidism SE fi ne tremor , nervous tension, headache, palpitation, muscle cramps BNF 3.1.1.1. Sando-K potassium sa lt see potassium oral supplement. Senna see laxatives. chronic OHFP.indb 214 OHFP.indb 214 30/05/2014 16:18 30/05/2014 16:18 215 pharmacopeia Seretide long-acting B2 agonist with corticosteroid Dose 25 \200\22350micrograms salmeter ol with 50 \200\223500micrograms fl uticasone/12 \200\223 24h INH (depends upon inhaler dev ice, see BNF) Indication asthma (see b p273) Caution cardiovascular disease, DM, hyperthyro idism, TB SE fi ne tremor, nervous tension, headache, palpitation, muscle cramps, oral cand idiasis, hoarse voice, paradoxical bronchospasm (rare) Interaction see salmeterol and fl ut icasone BNF 3.2. Sertraline selective serotonin re-uptake inhibitors Dose 50mg/24h PO increased by 50mg incr ements at intervals of at least 1wk until desired eff ect (max 200mg/24h) Indication depres sion, OCD, panic disorder CI hepatic or renal impairment, active mania Caution pregnancy, e pilepsy, cardiac disease, DM SE GI disturbance, anorexia, weight loss Interaction MAOI with in 2wk, inhibits p450 enzymes BNF 4.3.3. Sevredol opioid see oral morphine. Simvastatin H MG CoA reductase inhibitor see statin. Slow-K potassium salt see potassium oral supplemen t. Sodium valproate antiepileptic see valproate. Sotalol see beta-blockers. Spironolactone potassium-sparing diuretic (aldosterone antagonist) Dose 100 \200\223200mg/2 4h PO (max 400mg/24h) Indication oedema/ascites in cirrhosis/malignancy, nephritic syndrome , con- gestive heart failure CI pregnancy, breastfeeding, hyperkalaemia, hyponatraemia, Add ison \200\231s disease Caution renal impairment, porphyria SE GI disturbance, impotence, gy naecomastia, menstrual irregularities Interaction increases digoxin and lithium levels; ris k of iK+ when used with ACEi or AT II receptor antagonists BNF 2.2.3. Statins HMG CoA reductase inhibitor Dose see Table 5.18 Indications dyslipidaemias, primary and secondary prevention of cardio vascular disease (irrespective of serum cholesterol) Ca ution pregnancy, breastfeeding, hypothyroidism, hepatic impairment, high alcohol intake, SE myalgia, myositis (in severe cases rhabdomyolysis), GI disturbance, pancreatitis, altered LFTs (rarely hepatitis/jaundice) Interaction avoid concomitant use of macrolide antibiotics and ami- odarone (possible increased risk of myopathy) BNF 2.12. Table 5.18 Statins BNF 2.12 Dose initially 10mg/24h PO up to max 80mg/24h PO Dose initially 20mg/24h PO up to max 80mg/ 24h PO Dose initially 10mg/24h PO up to max 40mg/24h PO Dose initially 5mg/24h PO up to max 40mg/24h PO Dose initially 10mg/24h PO up to max 80mg/24h PO Atorvastatin Fluvastatin Pravastatin Rosuvastatin Simvastatin _OHFP.indb 215 _OHFP.indb 215 30/05/2014 16:18 30/05/2014 16:18 216 CHAPTER 5 Pharmacopeia Stemetil phenothiazine see antiemetic. Streptokinase plasminogen activator see fi brinoly tic. Sulfasalazine aminosalicylate Dose Maintenance: 500mg/6h PO; Acute: 1 \200\2232g/6h PO unti l remission; PR preparations also available Indication rheumatoid arthritis, ulcerative col itis, Crohn \200\231s disease CI sulfonamide sensitivity Caution pregnancy, breastfeeding, renal impair- ment, G6DP defi ciency SE GI disturbance, blood disorders, hepatotox- icity, discolored bodily fl uids BNF 1.5.1. Sulphonylureas Dose see Table 5.19 Indications type 2 DM CI ketoac idosis Caution pregnancy , breastfeeding, hepatic or renal impair- ment, porphyria; should not be fi rst-line agents in obese patients as will encourage further weight gain SE N+V, diarrhea, constipation, hy ponatraemia, hypoglycaemia, hepatic dysfunction, weight gain Info hypoglycaemia resulting f rom sulphonylureas can persist for many hours and must always be treated in hospital; sulph onylureas should not be given on the day of surgery due to the risk of hypoglycaemia BNF 6. 1.2.1. Table 5.19 Sulphonylureas BNF 6.1.2.1 Glibenclamide Dose 5mg (2.5 \200\22315mg) 24h PO mane Info long acting; use cautiously in the elderly Dose 40 \200\22380mg (40 \200\223160mg) usually 24h PO mane (max 320mg) Info medium acting Dose 2.5 \200\2235mg (2.5 \200\22315mg) usually 24h PO mane (max 20mg) Info short acting Dose 0.5 \200\2231.5g (0.5 \200\2232g) divided throughout the day P O with meals Info medium acting Gliclazide Glipizide Tolbutamide Symbicort long-acting B2 agonist with corticosteroid Dose 6 \200\22312micrograms formoter ol with 100 \200\223400micrograms budesonide/12 \200\223 24h INH (depends upon inhaler devi ce, see BNF) Indication asthma (see b p273), COPD Caution cardiovascular disease, DM, hyper thyroidism, TB SE fi ne tremor, nervous tension, headache, palpitation, muscle cramps, oral candidiasis, hoarse voice, paradoxical bronchospasm (rare) Interaction see salmeterol and fl uticasone BNF 3.2. Synacthen synthetic corticotrophin (ACTH) see tetracos- actide. Tam i \202 u antiviral see oseltamivir. Tamoxifen estrogen receptor antagonist Dose breast c ancer 20mg/24h PO; for other indications consult BNF Indication estrogen receptor-positive breast cancer, anovulatory infertility CI pregnancy Caution breastfeeding, increased risk o f thromboembolism, occasional cystic ovarian swellings in pre-menopausal women SE hot fl us hes, vaginal discharge/bleeding, menstrual suppression, GI disturbance Interaction increase s eff ects of warfarin BNF 8.3.4.1. OHFP.indb 216 OHFP.indb 216 30/05/2014 16:18 30/05/2014 16:18 217 pharmacopeia Tamsulosin A1 antagonist Dose 400micrograms/24h PO Indication benign prostatic hyperplasia CI breastfeeding, hypotension, hepatic impairment Caution renal impairment SE postural hypo tension, headache, dizziness, urinary incontinence Interaction increases eff ects of antihy pertensives BNF 7.4.1. Tazocin beta-lactam with tazobactam see piperacillin. Tegretol a ntiepileptic see carbamazepine. Teicoplanin glycopeptide antibiotic see vancomycin. Temazepam benzodiazepine Dose 10 \200\22320mg/24h PO at bedtime or pre-operative; dependenc y common (max 4wk course) Indication insomnia, pre-operative anxiety CI respiratory depress ion, sleep apnoea, unstable myasthenia gravis, hepatic impairment Caution pregnancy, breast feeding, history of drug abuse, respiratory disease, muscle weak- ness, renal impairment SE drowsiness, confusion, muscle weakness BNF 4.1.1/15.1.4.1. Tenecteplase plasminogen activator see fi brinolytic. Terbutaline B2 agonist Dose 500microg rams/6h INH; 5 \200\22310mg/6 \200\223 12h NEB; oral preparations are also available, consu lt BNF Indication asthma and other reversible airway obstruction Caution cardiovascular dis ease, DM, hyperthyroidism SE fi ne tremor, nervous tension, head- ache, palpitation, muscle cramps BNF 3.1.1.1. Tetanus vaccine and immunoglobulin see b p437. Tetracosactide (Synacth en ) synthetic corticotrophin (ACTH) Dose 250micrograms IV/IM Indication diagnosis of Addi son \200\231s disease Caution pregnancy, breastfeeding, allergic disor- ders SE Cushing \200\231s syndrome, DM, osteoporosis Info blood should be sampled for cortisol pre-dose and again at 30min post Synacthen dose (consultant local guidelines) BNF 6.5.1. Tetracycline tetracycline antibiotic Dose 250 \200\223500mg/6h PO Indication infection, acn e vulgaris CI pregnancy, breastfeeding, renal impairment, age <12y (irreversibly stains gro wing teeth and bones) Caution myasthenia gravis may worsen, exacerbates SLE SE GI disturban ce including, dysphagia/oesophageal irritation Interaction decreased absorption with milk, decreases eff ects of oral contraceptive pill, mildly increases eff ects of warfarin BNF 5. 1.3. _OHFP.indb 217 _OHFP.indb 217 30/05/2014 16:18 30/05/2014 16:18 218 CHAPTER 5 Pharmacopeia Theophylline methylxanthine Dose 200 \200\223500mg/12h PO (depending upon preparation, cons ult BNF) Indication severe asthma/ COPD (see BTS guidelines) CI acute porphyria Caution car diac disease, epilepsy, hyperthyroidism, peptic ulcer disease SE tachycardia, palpitation, GI disturbance Info theophylline is only available as an oral preparation; aminophylline co nsists of theophylline and ethylenediamine which simply improves the drug s solubility allo wing IV administration BNF 3.1.3. Toxic >20mg/l (>110micromol/l); signs of toxicity arrhythmia, anxiety, tremor, convulsions (OHAM3 b p731) Monitoring theophylline Thiamine vitamin B1 Dose oral 25 \200\223100mg/24h or 200 \200\223300mg/24h PO depending on severity (consult BNF); parenteral 2 \200\2233 pairs of ampoules/8h IV (Pabrinex ) (consu lt local guidelines) Indication nutritional defi ciency, especially alcoholism Caution repo rts of anaphylaxis with paren- teral preparations BNF 9.6.2. Thyroxine thyroid hormone (T4) see levothyroxine. Tinzaparin low-molecular-weight heparin D ose depends upon indication, consult BNF Indication DVT/PE prophylaxis and treatment CI bre astfeeding, bleeding disorders, thrombocytopenia, severe hyperten- sion, recent trauma Caut ion hyperkalaemia, hepatic or renal impairment SE hemorrhage, thrombocytopenia, hyperkalaem ia Interaction NSAIDs increase bleeding risk, eff ects increased by GTN BNF 2.8.1. Tiotropium antimuscarinic (anti-M3) Dose 18micrograms/24h INH; solution for inhalation also available (see BNF) Indication maintenance treatment of COPD Caution renal impairment, gla ucoma, prostatic hyper- trophy, cardiac rhythm disorders SE minimal antimuscarinic eff ects BNF 3.1.2. Tiro \201 ban glycoprotein IIb/IIIa inhibitor Dose initially: 400nano- grams/kg/min for 30 min IV then: 100nanograms/kg/min IV for at least 48h (max 108h treatment) Indication preven tion of MI in unstable angina/NSTEMI patients CI breastfeeding, abnormal bleeding/cerebro- vascular accident within 30d, history of haemorrhagic stroke, severe hypertension, intracra nial disease Caution pregnancy, hepatic or renal impairment, increased risk of bleeding, su rgery or major trauma within 3mth SE bleeding, reversible thrombocytopenia BNF 2.9. OHFP.indb 218 OHFP.indb 218 30/05/2014 16:18 30/05/2014 16:18 219 pharmacopeia Topical corticosteroids Dose consult BNF; guidance on applying topical steroids can be foun d on b p178 Indications infl ammatory conditions of the skin, eg eczema, contact dermatitis amongst others CI untreated bacterial, fungal, or viral skin lesions, rosacea, perioral de rma- titis, widespread plaque psoriasis Caution use lowest potency agent pos- sible (Table 5.20) for shortest duration of time to limit side eff ects SE local thinning of the skin, w orsening local infection, striae and telangiectasia, acne, depigmentation, hypertrichosis; systemic rarely adrenal suppression, Cushing \200\231s syndrome Info topical steroids shoul d only be commenced after seeking specialist advice (either following a dermatology review or after consideration by registrar). The decision to stop potent topical steroids should b e taken as seriously \200\223 always be mindful of the potential for a patient to develop an Addison crisis after stopping long-term potent topical steroids BNF 13.4. Table 5.20 Topical corticosteroid potencies BNF 13.4 Potency Examples Hydrocortisone 0.1 \200\2232.5%, Dioderm , Mildison , Synalar 1 in 10 dilution Betnovate-RD , Eumovate , Haelan , Modrasone , Synalar 1 in 4 dilution , Ultralanum P lain Mild Moderately potent Potent Beclometasone dipropionate 0.025%, Betamethasone valerate 0.1%, Betacap , Betesil , Betta mousse , Betnovate , Cutivate , Diprosone , Elocon , hydrocortisone butyrate, Locoid , Locoid Crelo , Metosyn , Nerisone , Synalar Clarelux , Dermovate , Etrivex , Neri sone Forte Very potent Tramadol opioid Dose 50 \200\223100mg/4h PO/IM/IV (max 600mg/24h in divided doses) Indicati on pain CI acute respiratory depression, paralytic ileus, raised ICP/head trauma, comatose patients, acute porphyria, uncon- trolled epilepsy Caution pregnancy (especially delivery), breastfeeding, COPD, asthma, arrhythmias, hepatic or renal impairment SE N+V consti- patio n, respiratory depression, dry mouth Interaction MAOI within 2wk Info co-prescribe laxative s if using opioids for >24h BNF 4.7.2. Trimethoprim antibiotic Dose acute infection: 200mg/12h PO; prophylaxis: 100mg/24h PO at ni ght Indication urinary tract infections CI blood dyscrasias Caution pregnancy, breastfeedin g, renal impairment, folate defi ciency SE GI disturbance, rash, hyperkalaemia Interaction increases phenytoin levels, increases risk of arrhythmias with amiodarone BNF 5.1.8. _OHFP.indb 219 _OHFP.indb 219 30/05/2014 16:18 30/05/2014 16:18 220 CHAPTER 5 Pharmacopeia Valproate antiepileptic Dose 300mg/12h PO increasing by 200mg every 3d (max 2.5g/24h in div ided doses) Indication epilepsy: all forms CI family history of hepatic dysfunction, acute porphyria Caution pregnancy, breastfeeding, hepatic or renal impairment, blood disorders (b leeding risk), SLE, pancreatitis SE GI disturbance, sedation, headache, cerebellar eff ects , hepatotoxicity, blood disorders Interaction eff ects decreased by antima- larials, antide pressants, antipsychotics and antiepileptics BNF 4.8.1. Trough 350 \200\223700micromol/l (50 \200\223100mg/l); toxic >1260micromol/l (>180mg/l) Monitoring valproate Valsartan see AT II antagonists. Vancomycin glycopeptide antibiotic Dose 125mg/6h PO; 1 \200\2231.5g/12h IV; some centers us e continuous infusions of vancomycin (consult local guidelines) Indication serious Gram +ve infections: endo- carditis, MRSA, antibiotic associated colitis Caution pregnancy, breast- feeding, renal impairment, avoid rapid infusion, history of deafness, infl ammatory bowel disease SE nephrotoxicity, ototoxicity, blood dis- orders, rash (red man syndrome) Interact ion increased nephrotoxicity with ciclosporin, increased ototoxicity with loop diuretics BN F 5.1.7. Usually before 3rd or 4th dose (check local guidelines) trough 10 \200\22315mg/l; toxicity can occur within therapeutic range Monitoring vancomycin Venlafaxine serotonin and noradrenaline re-uptake inhibitor Dose initially 37.5mg/12h, incr ease if necessary at intervals of >2wks to 75mg/12h (max 375mg per 24h) Indication major de pression, generalized anxiety disorder CI breastfeeding, high risk of cardiac arrhythmia, u ncon- trolled hypertension Caution pregnancy, hepatic or renal impairment, heart disease, e pilepsy, history of mania, glaucoma SE GI disturbance, hyperten- sion, palpitation, dizzine ss, drowsiness Interaction MAOIs within 2wk, increased risk of bleeding with aspirin/NSAIDs , CNS toxicity with selegiline, mildly increases eff ects of warfarin BNF 4.3.4. Ventolin B2 agonist see salbutamol. Verapamil see calcium-channel blockers. Vitamin K see phytomenadione. OHFP.indb 220 OHFP.indb 220 30/05/2014 16:18 30/05/2014 16:18 221 pharmacopeia Warfarin coumarin Dose loading: see b p407; maintenance: typically 1 \200\2235mg/24h PO dic tated by the patient \200\231s INR (though higher doses and dosing on alternative days are not uncommon) Indication prophylaxis of thromboembolism (atrial fi brillation, mechanical h eart valves etc), treatment of venous thrombosis or pulmonary embolism CI pregnancy, peptic ulcers, severe hypertension, bacterial endocarditis Caution breastfeeding, hepatic or rena l impairment, conditions in which risk of bleeding is increased (eg GI bleeding, peptic ulc er, recent surgery, recent ischaemic stroke, postpartum, bacterial endocarditis), uncon- tr olled hypertension recent SE hemorrhage, rash, alopecia Interaction avoid cranberry juice ( ianticoagulant eff ect) Info warfarin is available in tablets of 0.5mg (white), 1mg (brown) , 3mg (blue), and 5mg (pink) but check which tablets are stocked locally BNF 2.8.2. Zolpidem non-benzodiazepine hypnotic Dose 10mg/24h PO at night Indication short-term treatm ent of insomnia CI breastfeeding, severe hepatic impairment, psychotic illness, neuromuscul ar respiratory weakness, unstable myasthenia gravis, respiratory failure, sleep apnoea Caut ion pregnancy, hepatic or renal impairment, muscle weakness, history of drug abuse SE taste disturbance, GI disturbance, headache BNF 4.1.1. Zopiclone non-benzodiazepine hypnotic Dose 3.75 \200\223 7.5mg/24h PO at night Indication s hort-term treatment of insomnia CI breastfeeding, severe hepatic impairment, neuromuscular respiratory weakness, unstable myasthenia gravis, respiratory failure, sleep apnoea Caution pregnancy, hepatic or renal impairment, muscle weakness, history of drug abuse SE taste di sturbance, GI disturbance, headache BNF 4.1.1. Zoton proton pump inhibitor see lansoprazo le. Zyban treatment of nicotine dependence see bupropion. _OHFP.indb 221 _OHFP.indb 221 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank Chapter 6 Resuscitation 223 Early warning scores 224 Peri-arrest 226 In-hospital resuscitation 227 Advanced Life Suppor t (ALS) 228 Arrest equipment and tests 230 Advanced Trauma Life Support (ATLS) 232 Pediatri c Basic Life Support 234 Newborn Life Support (NLS) 236 Obstetric arrest 238 _OHFP.indb 223 _OHFP.indb 223 30/05/2014 16:18 30/05/2014 16:18 224 CHAPTER 6 Resuscitation Early warning scores Early detection of the \200\230unwell \200\231 patient has repeatedly been shown to improve outcome. Identifi cation of such patients allows suitable changes in management, including early involvement of critical care teams or transfer to critical car e areas (HDU/ICU) where necessary. Identi \201 cation of the \200\230at-risk \200\231 patient relies on measurement of simpl e physiological parameters, which generally deteriorate as the patient becomes more unwell; these include RR, HR, BP, O2 saturation, level of consciousness, and temp. Remember that t he sick patient might not always look that unwell from the bottom of the bed. Scoring of these parameters can be carried out in many ways and is usually undertaken by nu rsing staff . Considerable variation still exists in the format of scoring systems in use i n individual hospitals, and in the actions that are triggered when certain thresholds are r eached. A national project to standardize these approaches into a single National Early Wa rning Score (NEWS) is being led by the Royal College of Physicians.1 Their scoring system is shown in Table 6.1. Normal obser- vations are awarded a score of 0, whilst abnormal obse rvations attract higher scores. The values for each physiological parameter are added toget her. If this total score reaches a \200\230threshold \200\231 value ( \211 5, or any indi- vidual parameter scoring 3), the nursing staff should increase frequency of observations a nd alert a doctor to review the patient, depending on local policy/guidelines. Trends in physiological parameters are often more useful than one-off observations. Some pa tients may have abnormal scores even when they seem relatively \200\230well \200\231 becau se of compensatory mechanisms. For these patients, higher thresholds may be agreed by senio r doctors, but bear in mind that they are also likely to deteriorate much more quickly. Patients who should be monitored by such scores include: \200 Emergency admissions \200 Unstable patients \200 Elderly patients \200 Patients with pre-existing disease (cardi ovascular, respiratory, DM) \200 Patients who are failing to respond to treatment \200 Patients who have returned from ICU/HDU \200 Post-operative patients. ALERT \204 Acute Life-threatening Events: Recognition and Treatment This is an evolving co urse that aims to guide people in early recogni- tion of the unwell patient and in their im mediate resuscitation. This course complements the Immediate Life Support (ILS) and Advance d Life Support (ALS) courses (b p228). Further information can be found at (cid:27)www.aler t-course.com 1 (cid:27)www.rcplondon.ac.uk/resources/national-early-warning-score-news See also NICE gui de- lines at (cid:27)guidance.nice.org.uk/CG50 OHFP.indb 224 OHFP.indb 224 30/05/2014 16:18 30/05/2014 16:18 _ _ O O H H F F P P i i n n d d b b 2 2 2 2 5 5 35.1 - 36.0 36.1 - 38.0 (cid:22)(cid:27)(cid:17)(cid:20)(cid:3)(cid:16)(cid:3)(cid:22)(cid:28)(cid:17)(cid:19) (cid:149)(cid:22)(cid:28)(cid:17)(cid:20) E A R L Y W A R N N G S C O R E S (cid:24)(cid:20)(cid:3)(cid:16)(cid:3)(cid:28)(cid:19) The NEWS initiative flowed from the Royal College of Physicians NEWSDIG, and was jointly d eveloped and funded in collaboration with the Royal College of Physicians, Royal College of Nursing, National Outreach Forum and NHS Training for Innovation. I Table 6.1 National Early Warning Score (NEWS). A total score \211 5, or any individual par ameter scoring 3 should prompt urgent review by a doctor. Reproduced from Royal College of Physicians. National Early Warning Score (NEWS): Standardizing the assessment of acute-illn ess severity in the NHS. Report of a working party. London: RCP, 2012. 2 2 5 3 3 0 0 / / 0 0 5 5 / / 2 2 0 0 1 1 4 4 1 1 6 6 1 1 8 8 : : 226 CHAPTER 6 Resuscitation Peri-arrest Check airway is patent; consider maneuvers/adjuncts with C-spine control in trauma If no re spiratory eff ort \200\223 CALL ARREST TEAM If no palpable pulse \200\223 CALL ARREST TEA M If GCS \211 8 \200\223 CALL anesthetist Airway Breathing Circulation Disability Airway \200\223 if irreversibly obstructed CALL ARREST TEAM \200 Look inside the mouth, remove obvious objects/dentures \200 Wide-bore suction under direct vision if secretions present \200 Listen airway impaired if stridor, snoring, gurgling or no air entry \200 Jaw thrust/head tilt/chin lift with cervical spine control in trauma \200 Oropharyngeal o r nasopharyngeal airway as tolerated \200 If still impaired CALL ARREST TEAM. Breathing \200\223 if poor or absent respiratory eff ort CALL ARREST TEAM \200 Look for chest expan sion (does R = L?), fogging of mask \200 Listen to chest for air entry (does R = L?) \200 Feel for expansion and percussion (does R = L?) \200 Non-rebreather (trauma) mask a nd 15l/min O2 initially in all patients \200 Bag and mask if poor or absent breathing eff ort \200 Monitor O2 sats and RR \200 Think tension pneumothorax. Circulation \200\223 if no pulse CALL ARREST TEAM \200 Look for pallor, cyanosis, distended neck veins \200 Feel for a central pulse (carotid/femoral) \200\223 rate and rhythm \200 Monitor defi b rillator ECG leads and BP \200 Venous access, send bloods if time allows \200 12-lead E CG \200 Call for senior help early if patient deteriorating. Disability \200\223 if GCS \211 8 or falling CALL anesthetist \200 Assess GCS (b p338) and check glucose \200 Loo k for pupil refl exes and unusual posture \200 Feel for tone in all four limbs and planta r refl exes. Exposure \200 Remove all clothing, check temp \200 Look all over body incl uding perineum and back for rash or injuries \200 Cover patient with a blanket. Common causes b p248 Arrhythmia b p244 Myocardial infarction b p379 Hypovolaemia Sepsis (UTI/pneumonia) b p480 b p322 Hypoglycaemia b p271 Hypoxia b p272 Pulmonary oedema b p278 Pulmonary embolism Metabolic (idK+) b p384 (T ension) pneumothorax b p279 OHFP.indb 226 OHFP.indb 226 30/05/2014 16:18 30/05/2014 16:18 227 IN-HOSPITAL RESUSCITATION In-hospital resuscitation Collapsed/sick patient Shout for HELP and assess patient Signs of life? NO YES Assess ABCDE Recognize and treat Oxygen, monitoring, IV access Call resuscitation team CPR 30:2 with oxygen and airway adjuncts Call resuscitation team if appropriate Apply pads/monitor Attempt defibrillation if appropriate Handover to resuscitation team Advanced Life Support when resuscitation team arrives Fig. 6.1 In-hospital resuscitation algorithm; 2010 guidelines. Reproduced with the kind per mission of the Resuscitation Council (UK). Signs of life Regular respiratory eff ort Coughing Purposeful movement Speaking Opening eyes _OHFP.indb 227 _OHFP.indb 227 30/05/2014 16:18 30/05/2014 16:18 228 CHAPTER 6 Resuscitation ) Advanced Life Support (ALS) pp ( Check airway is patent; consider maneuvers/adjuncts with C-spine control in trauma If no re spiratory eff ort \200\223 CALL ARREST TEAM If no palpable pulse \200\223 CALL ARREST TEA M Airway Breathing Circulation Basic life support should be initiated and the cardiac arrest team called as soon as cardia c or respiratory arrest is identifi ed. Advanced life support is centered around a \200 \230universal algorithm \200\231 (Fig. 6.2) which is taught on a standardized course off er ed by most hospitals. The cardiac arrest team usually consists of a team leader (medical St R), F1, anesthetist, CCU nurse and senior hospital nurse: \200 Team leader \200\223 give s clear instructions to other members \200 F1 \200\223 provide BLS, cannulate, take arte rial blood, defi brillate if trained, give drugs, perform chest compressions Anesthetist \200\223 airway and breathing, they may choose to bag-and-mask ventilate the patient, insert a laryngeal mask or intubate (b p542) Nurses \200\223 provide BLS, defi brillate if trained, give drugs, perform chest compressi ons, record observations, note time points, and take ECGs. Needle-stick injuries (b p106) a re commonest in times of emer- gency. Have the sharps box nearby and never leave sharps on the bed. Cannulation can be very diffi cult during a cardiac arrest. The ante- cubital foss a is the best place to look fi rst; alternatively try feet, hands, forearms, or consider ex ternal jugular if all else fails. Take bloods if you are successful, but don \200\231t allo w this to delay the giving of drugs. Blood tests are occasionally useful in cardiac arrests , especially K+ which can often be measured by arterial blood gas machines. Use a blood gas syringe to obtain a sample (the femoral artery with a green needle (21G) is often easiest \200\223 NAVY, b p516) and ask a nurse to take the sample to the machine. Other blood test s depend on the clinical scenario; if in doubt fi ll all the common blood bottles. De \201 brillation is taught on specifi c courses (eg ILS, ALS) and must not be undertaken unless trained. The use of automated external defi brilla- tors or AEDs (b p532) is becoming routi ne. Cardiac arrest drugs are now prepared in pre-fi lled syringes: adrena- line (epinephrin e) 1mg in 10ml (1:10,000), atropine (several preparations available), amiodarone 300mg in 1 0ml. Always give a large fl ush (20ml saline) after each dose to encourage it into the cent ral circulation. See b inside back cover for further emergency drug doses. Cardiac arrest t rolleys are found in most areas of the hospital. Know where they are for your wards. Ask th e ward sister if you can open the trolley and have a good look at the equipment within it a s they diff er between hospitals. They are often arranged so the top drawer contains Airway equipment, the second contains Breathing equipment, the third contains Circulation equipme nt and the lower drawer contains the drugs and fl uids. You \200\231ll seldom need anything that isn \200\231t on the trolley. OHFP.indb 228 OHFP.indb 228 30/05/2014 16:18 30/05/2014 16:18 229 ADVANCED LIFE SUPPORT (ALS) Unresponsive? Not breathing or only occasional gasps Call resuscitation team CPR 30:2 Attach defibrillator/monitor Minimize interruptions Assess rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) Return of spontaneous circulation 1 Shock Immediately resume CPR for 2 min Minimize interruptions Immediately resume CPR for 2 min Minimize interruptions Immediate post cardiac arrest treatment \200 Use ABCDE approach \200 Controlled oxygena tion and ventilation \200 12-lead ECG \200 Treat precipitating cause \200 Temperature control/ therapeutic hypothermia Reversible Causes During CPR Hypoxia \200 Hypovolaemia \200 Hypo-/hyperkalaemia/metabolic \200 Hypothermia Ensure high-quality CPR: rate, depth, recoil \200 Plan actions before interrupting CPR \200 Give oxygen \200 Consider advanced airway and capnography \200 Continuous chest c ompressions when advanced airway in place \200 Vascular access (intravenous, intraosseous ) \200 Give adrenaline every 3 \200\2235 min \200 Correct reversible causes Thrombosis - coronary or pulmonary \200 Tamponade - cardiac \200 Toxins \200 Tension pneumothorax Fig. 6.2 Adult Advanced Life Support algorithm; 2010 guidelines. Reproduced with the kind p ermission of the Resuscitation Council (UK). _OHFP.indb 229 _OHFP.indb 229 30/05/2014 16:18 30/05/2014 16:18 230 CHAPTER 6 Resuscitation Arrest equipment and tests Airway Jaw thrust Pull the jaw forward with your index and middle fi ngers at the angle of each mandible. Pull hard enough to make your fi ngers ache. Head tilt Gently extend the neck, avoid if C-spine injury risk. Chin lift Pull the chin up with two fi ngers, avoid if C-spine injury risk. Oropharyngeal airway (Guedel) A rigid, curved plastic tube; choose the size that reaches th e angle of the mouth from the tragus of the ear. Insert upside down to avoid pushing the to ngue back, then rotate 180 when inside the mouth (do not insert upside down in children). Nasopharyngeal airway A fl exible, curved plastic tube, not to be used with signifi cant he ad injury. Choose the size that will easily pass through the nose (size 6 \200\2237mm in mo st adults); insert by lubricating and pushing horizontally into the patient \200\231s nostr il (not upwards). Use a safety pin through the end to prevent the tube being lost. Suction Cover the hole on the side of a wide-bore suction catheter to cause suction at the tip. Secretions in the parts of the oropharynx that can be seen directly can be cleared. A thinner catheter can be used to clear secretions in the airway of an intubated patient. Breathing Non-rebreather mask (trauma mask) A plastic mask with a fl oppy bag attached; use d in acutely ill patients to give 780% O2 with a 15l/min fl ow rate. Standard mask (Hudson mask) A plastic mask that connects directly to O2 tubing; delivers 75 0% O2 with a 15l/min fl ow rate. Venturi A mask that connects to the O2 tubing via a piece of colored plastic, delivering either 24%, 28%, 35%, 40%, or 60% O2. Adjust the fl ow rate according to the instructions on the colored plastic con- nector, eg 4l/min with the 28% Ve nturi connection. Bag and mask (Ambu bag) A self-infl ating bag and valve that allows you to force O2 into an inadequately ventilating patient. Attach the O2 tubing to the bag with a 15l/min fl ow rat e then seal the mask over the patient \200\231s nose and mouth. Easiest with two people; on e person stands at the head to get a fi rm seal with both hands whilst the other squeezes t he bag. The mask can be removed to attach the bag to an ETT or LMA (b p544). Pulse oximeter Plastic clip with a red light that measures blood O2 satura- tions. Clip ont o the patient \200\231s index fi nger. Do not rely on the reading unless there is an even t race on the monitor and the patient has a pulse; use on the diff erent arm from the BP cuff . Nebuliser This is a 3cm-high cylinder that attaches beneath a mask. The cylinder is made of two halves that can be untwisted so that the fl uid to be nebulised can be inserted. The n ebuliser can be connected to a pump or directly to an O2 or medical air supply. OHFP.indb 230 OHFP.indb 230 30/05/2014 16:18 30/05/2014 16:18 231 ARREST EQUIPMENT AND TESTS Circulation De \201 brillation (b p532) Successful defi brillation requires ECG monitoring to identify a shockable rhythm, and delivery of current through elec- trodes attached to t he chest wall. Previously, monitoring was performed using ECG leads: red to right shoulder, yellow to left shoulder and green to apex (b p528). Separate paddles were applied to deliv er current. Most NHS trusts now use hands-free adhesive defi brillation electrodes which ar e safer and also double as monitoring leads (b p533). Only defi brillate if you have been t rained: \200 Check the adhesive electrodes are correctly applied to the chest \200 Swit ch the defi brillator to \200\230monitor \200\231 mode \200 If a shockable rhythm is ide ntifi ed, select required defi brillation energy using the circular dial, then charge defi brillator using \200\230charge \200\231 button \200 Tell staff to stand clear and stand clear yourself - try to minimize the interruption of chest compressions which should contin ue until the latest possible moment