I
I
É
CLINICAL PRACTICE
Andrew Baird
MA, MBChB, DRANZCOG, DA, FRACGP, FACRRM,
is a general practitioner, Brighton, Victoria.
bairdak@gmail.com
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
• Activate 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)
• paediatric dosage: 0.01 mg/kg (10 µg/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 µg/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 µg/kg) (Table 3)
– in adults, if there is a poor response, consider glucagon 1–2 mg
IV over 5 minutes
– consider 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 <90%,
agitated, confused, drowsy, maximal accessory muscle use and recession).
Adult:
• oxygen, at least 8 L/min to maintain SpO2 >94%
• nebulised salbutamol 10 mg driven by oxygen, at least 8 L/min every
15 minutes
• nebulised ipratropium 500 µg 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 µg/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 µg for adults, 5 µg/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 µg/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 µg/dose MDI via spacer, six puffs every 2 hours,
OR ipratropium 500 µg 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
Contraindications (other than known allergy)
Adverse reactions
Adrenaline: 1 mg/1 mL
(1:1000)
Atropine: 600 µg/1 mL
ADT: 0.5 mL vial
Nil in cardiac arrest and anaphylaxis
Benztropine: 2 mg/2 mL
Benzylpenicillin powder:
600 mg or 3 g
Dexamethasone: 4 mg/1 mL
Diazepam: 10 mg/2 mL
Children <3 years of age
Nil
Arrhythmia; myocardial and cerebrovascular
ischaemia
Tachycardia, confusion, nausea
Local: pain, swelling
Systemic: fever, malaise
Tachycardia, confusion
Nil
Dihydroergotamine: 1 mg/1 mL
Frusemide: 20 mg/2 mL
Glucagon: 1 mg/1 mL
GTN spray: 400 µg/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
542 Reprinted from AUSTRALIAN FAMILY PHYSICIAN Vol. 37, No. 7, July 2008
Nil in cardiac arrest or hypotensive bradycardia
Children <8 years of age
Nil in emergency
Cardiorespiratory failure
Central nervous system (CNS) depression
Hemiplegic migraine
Use of sumatriptan
Sulfonamide allergy
Nil
Cardiogenic shock
Systolic blood pressure <100 mmHg
Use of phosphodiesterase type 5 (PDE5) inhibitors
Cardiovascular collapse
CNS depression
Nil in emergency
Nil
Acute complete bowel obstruction
Rare with single dose
Drowsiness, confusion, respiratory
depression
Vasospasm syndromes (rare)
Nil
Nil
Headache, hypotension
Dystonia, confusion, hypotension
Rare with single dose
Respiratory or CNS depression
Lightheadedness, nausea, agitation
Dystonic reactions (~1%, more common in
children)
Sedation, nausea, vomiting
Nil
Nil
Circulatory collapse
CNS depression
Drowsiness
Emergency drugs in general practice CLINICAL PRACTICE
Table 2. Emergency drugs: presentation, contraindications, and potential adverse reactions (in emergency use) continued
Drug presentation
Salbutamol:
MDI: 100 µg/dose
Nebuliser: 2.5 mg or 5.0 mg/2.5 mL
Tramadol: 100 mg/2 mL
Verapamil: 5 mg/2 mL
Aspirin*#: 300 mg tablet
Ceftriaxone*#: 2 g powder
Diclofenac*:
tablets: 50 mg
suppositories: 100 mg
Glucose*# 50% (500 mg/mL): 50 mL
Ipratropium bromide*#:
MDI: 20 µg/dose
Nebuliser: 500 µg/1 mL
Ketorolac*: 10 mg/1 mL
Midazolam*#: 5 mg in 1 mL
(or 15 mg in 3 mL)
Olanzapine*: 5 mg wafer or tablet
Sumatriptan*:
tablets: 50 mg, 100 mg
injection: 6.0 mg in 0.5 mL
Syntometrine* 1 mL
(oxytocin 5 intra-uterine (IU) plus
ergometrine 500 µg)
Contraindications (other than known allergy)
Nil
Adverse reactions
Tachycardia, tremor
Children, MAOIs, respiratory or CNS depression;
caution with SSRI drugs
Cardiogenic shock, heart block, hypotension, broad
complex SVT, use of beta blocker drugs
Active haemorrhage, active gastrointestinal ulcer;
caution in asthma
Nil
Active gastrointestinal ulcer or haemorrhage;
caution in: renal impairment, anticoagulation,
asthma
Nausea, vomiting, dizziness
Diabetic coma
Nil
Phlebitis
Nil
Active gastrointestinal ulcer or haemorrhage; caution
in: renal impairment, anticoagulation, asthma
Cardiorespiratory failure
CNS depression
Nil
Ischaemic heart disease
Cerebrovascular disease
Ergotamine <24 hour ago
Caution: taking SSRI, SNRI
Threatened abortion
Severe hypertension
Nausea, dyspepsia
Nausea, heart block, bradycardia,
hypotension
Dyspepsia
Nil
Nausea, dyspepsia
Drowsiness, confusion, respiratory
depression
Hypotension
Transient flushing, dizziness, tightness in
chest or throat, increased BP
Hypertension
Headache
Nausea
* Not supplied under PBS emergency drug (doctor’s bag) items # Drugs are carried by MICA paramedics in Victoria
MAOI = monoamine oxidase inhibitor, SSRI = selective serotonin reuptake inhibitor, SNRI = selective noradrenaline reuptake inhibitor
Paediatric:
• oxygen at least 8 L/min to maintain SpO2 >94%
• salbutamol 100 µg/dose MDI via spacer, 4–6 tidal breaths per puff,
repeat after 20 minutes for two further doses if not improved
– over 6 years of age: 12 puffs
– 6 years of age or under: 6 puffs
And
• prednisolone 1 mg/kg orally.
Acute exacerbation of chronic obstructive pulmonary disease4
Treat as acute asthma, with the following exceptions:
• controlled oxygen therapy to reduce the risk of inducing hyperoxic
hypercapnia. In practice, oxygen at 2 L/min via nasal prongs is
indicated to achieve oxygen saturation of 90–93%
• nebulised bronchodilators should be driven with high flow air,
not oxygen
• start antibiotics for clinical signs of infection (eg. oral doxycycline).
Acute coronary syndrome5
• Oxygen 8 L/min
• Aspirin 300 mg orally
• Glyceryl trinitrate (GTN) spray, 1 dose repeated after 5 minutes if no
improvement
• Morphine 2.5 mg IV every 5 minutes as required, titrated to analgesic
effect (maximum of 15 mg).
All patients with acute coronary syndrome (ACS) should be stabilised
and transferred to hospital as soon as possible.
Fibrinolysis (for ACS with ST elevation or new left bundle branch
block) in an out-of-hospital setting is controversial. Patients who present
to a rural hospital less than 12 hours from symptom onset may be
considered for fibrinolysis if percutaneous coronary intervention is not
possible within 1–2 hours. A cardiologist should be consulted.
Severe upper airway obstruction
• Nebulised adrenaline (1 mg in 1 mL ampoules):
Reprinted from AUSTRALIAN FAMILY PHYSICIAN Vol. 37, No. 7, July 2008 543
CLINICAL PRACTICE Emergency drugs in general practice
– adult dosage: 5 mL
– paediatric dosage: 0.5 mL/kg (maximum dose: 5.0 mL); dilute to
5.0 mL if necessary.
And/or:
• Glucose 50% IV at 3 mL/min via large vein
– adult and paediatric dosage: 20–50 mL (depending on response).
Acute pulmonary oedema
Convulsive status (convulsion for longer than 10 minutes)
• Oxygen 8 L/min – patient must be sitting up
• GTN spray, one dose, repeat every 5 minutes as required
• Frusemide 20 mg IV (consider 40 mg in patients currently taking
frusemide)
• Consider morphine 2.5 mg IV.
• Oxygen 8 L/min
• Diazepam
– adult dosage: 5–10 mg IV or 10–20 mg per rectum (PR) (insert nozzle
of syringe PR, can dilute with 5 mL of saline)
– paediatric dosage: (Table 3)
Or
• Midazolam (dose can be repeated after 15 minutes if there is
persistent or recurrent convulsion)
– adult dosage: 5–10 mg IM or 2.5–5.0 mg IV
– paediatric dosage: 0.2 mg/kg IM or 0.1 mg/kg IV.
Arrhythmias
Adults
• Cardiac monitoring is essential.
• Supraventricular tachycardia (SVT): consider verapamil 5 mg IV over
1 minute if symptomatic and if vagal manoeuvres have failed
• Bradycardia and ventricular arrhythmias – as described under
‘cardiac arrest’.
Adenosine by rapid IV bolus (6 mg then 12 mg if required) is now the
drug of first choice for converting SVT, and GPs may consider this. It is
potentially safer than verapamil, which may result in VF if given to treat
VT which has been misdiagnosed as broad complex SVT.
Opioid induced respiratory depression
• Normal saline IV
• Adult dosage: 500 mL–1L bolus then infusion to maintain circulation
• Paediatric dosage: 20 mL/kg bolus then infusion to maintain
circulation.
• Oxygen 8 L/min
• Naloxone
– adult dosage:
– titrated IV bolus (preferred): 0.1 mg at 1–2 minute intervals
– IM (if no IV access): 0.4 mg, repeat every 3 minutes as required (to a
maximum of 10 mg)
– paediatric dosage: 10 µg/kg IM initially; second dose 100 µg/kg if
required.6
Titration reduces the risk of precipitating withdrawal symptoms. Patients
should be observed for renarcotisation; naloxone infusion may be
required.
Postpartum haemorrhage and incomplete abortion
Meningitis and/or meningococcaemia (suspected)
• Syntometrine 1 mL IM.
• Benzylpenicillin, preferably IV but IM acceptable
– adult dosage: 1.2 g
– paediatric dosage:
– age <1 year: 300 mg
– age 1–9 years: 600 mg
– age >9 years: 1.2 g
Hypovolaemia
Hypoglycaemia
• Glucagon IV, IM, or SC
– adult (and children over 8 years of age) dosage: 1 mg
– children 8 years or under dosage: 0.5 mg
Table 3. Paediatric dosage chart for adrenaline and diazepam
Approximate
age
Approximate
weight (kg)*
Adrenaline
1 mg/1mL
0.01 mL/kg†
Adrenaline
1 mg/10 mL
0.1 mL/kg†
Diazepam IV
10 mg/2 mL
0.04 mL/kg
6 months
1–2 years
2–3 years
4–6 years
7–8 years
9–10 years
11–12 years
>12 years
8
10
15
20
25
30
35
40
0.05 mL
0.10 mL
0.15 mL
0.20 mL
0.25 mL
0.30 mL
0.35 mL
0.40 mL
0.5 mL
1.0 mL
1.5 mL
2.0 mL
2.5 mL
3.0 mL
3.5 mL
4.0 mL
0.2–0.3 mL
0.4 mL
0.6 mL
0.8 mL
1.0 mL
1.2 mL
1.4 mL
1.6 mL
Note: A useful approximation for a child’s weight is: 9 + (age x 2) kg
† = 0.01 mg/kg (10 µg/kg)
‡ = maximum recommended dosage
544 Reprinted from AUSTRALIAN FAMILY PHYSICIAN Vol. 37, No. 7, July 2008
Diazepam PR
10 mg/2 mL
0.10 mL/kg
0.5–0.8 mL
1.0 mL
1.5 mL
2.0 mL
2.5 mL
3.0 mL‡
3.0 mL‡
3.0 mL‡
Emergency drugs in general practice CLINICAL PRACTICE
• Ceftriaxone (if known allergy to penicillin)
– adult dosage: 2 g IV or IM
– paediatric dosage: 50 mg/kg IV or IM (maximum 2 g)
• Dexamethasone (0.15 mg/kg IV (maximum 10 mg)) may also be
administered on specialist advice.
Septicaemia (suspected)
• Ceftriaxone
– adult dosage: 2 g IV or IM
– paediatric dosage: 50 mg/kg IV or IM (maximum 2 g).
Nonlife threatening emergencies
Nausea and vomiting
Adults:
• metoclopramide 10 mg, IV, IM or SC
• prochlorperazine 12.5 mg IM is effective for nausea and vomiting
associated with vertigo, related to vestibular system disorders.
Metoclopramide has a higher risk of dystonic reactions in children than
in adults, and its use in children should be avoided. Metoclopramide has
no place in the management of a child with gastroenteritis.
Severe acute pain
• Pethidine has no place in the management of pain due to its high
potential for dependence and its neurotoxic metabolites
• Consider and exclude drug seeking behaviour before administering
opioids.
In most contexts, severe pain can be treated with:
• morphine (preferably IV, but can be given IM or SC)
– adult dosage: 2.5–5.0 mg, titrate to analgesic effect every 5 minutes
up to a maximum of 15 mg
– paediatric dosage: 0.1 mg/kg (avoid in infants)
• consider an antiemetic
Or (for moderate pain in adults):
• Tramadol 50–100 mg slow IV or IM.
Migraine (adult)
• Aspirin 900 mg orally
• Metoclopramide 10 mg IV
• Normal saline 1 L IV over 1–4 hours
• Alternatives to aspirin:
– dihydroergotamine 1 mg IM
– diclofenac 50–100 mg orally or PR
– sumatriptan 50–100 mg orally.
Table 4. Intravenous adrenaline in low cardiac output states and life threatening asthma
• Ambulance clinical practice guidelines describe the use of diluted incremental
doses of IV adrenaline every 2 minutes as required to maintain blood pressure
and perfusion
• Initial doses 10 µg. If there is inadequate response, doses are increased to
50 µg and then if necessary to 100 µg
• For 10 µg doses, add adrenaline 1 mg to a 1 L bag of normal saline to give a
solution of adrenaline 1 µg/mL. Ensure that the bag is labelled. Withdraw
10 mL for each dose
• For 50 µg and 100 µg doses, add an adrenaline 1 mg/mL 1 mL ampoule to 9 mL
of normal saline to give a solution of adrenaline 100 µg/mL. Ensure that the
syringe is labelled. Add the required volume of this solution (0.5 mL or 1.0 mL)
to a syringe with 10 mL of normal saline to give the diluted dose of adrenaline
• An infusion of normal saline should be running when adrenaline is used
intravenously
• IV adrenaline should only be used with extreme caution. Cardiac monitoring
is essential
Palliative care emergencies
Seidel et al7 have written a review on the use of doctor’s bag drugs in the
management of these emergencies.
Psychiatric emergencies (adults)
Acute psychosis, mania, severe agitation, severe anxiety or panic attack,
delirium (pending diagnosis and definitive treatment):
• diazepam 5–20 mg orally, or
• olanzapine 5 mg orally, or
• midazolam 2.5–10.0 mg IM or 2.5–5.0 mg IV every 20 minutes as
required (especially for drug induced states), or
• haloperidol 2.5–5.0 mg IM or IV.
With severe disturbance, IV access will be impossible.
Dystonic drug reaction:
• benztropine IV or IM
– adult dosage: 1–2 mg
– paediatric dosage: 0.02 mg/kg.
Contaminated wounds
Cleaning and debridement is the principal management.
Adult diphtheria and tetanus (ADT) 0.5 mL IM should be given if:
• tetanus prone wound, if more than 5 years since last dose of tetanus
toxoid
• any wound, if more than 10 years since last dose of tetanus toxoid
• uncertainty that primary course has been completed.
Ureteric colic and biliary colic
Emergency drugs provided under the PBS
Nonsteroidal anti-inflammatory drug (NSAID), eg. diclofenac 100 mg PR
or ketorolac 10 mg IM.
General practitioners can submit a monthly order form to a pharmacist
for the supply of Pharmaceutical Benefits Scheme (PBS) doctor’s bag
drugs at no cost. Alternative drugs may be preferable for managing
some emergencies.
• Chlorpromazine may cause hypotension; should be used with
extreme caution
Painful wounds
Consider using plain lignocaine by infiltration, topical application
(eg. eyes, ears) or ring block.
Reprinted from AUSTRALIAN FAMILY PHYSICIAN Vol. 37, No. 7, July 2008 545
CLINICAL PRACTICE Emergency drugs in general practice
• Midazolam is more versatile than diazepam. It can be used to manage
convulsions and agitated states, and, unlike diazepam, can be given
IM, buccally and intranasally. It can be given IV at half the IM dose
• Dihydroergotamine is less effective than sumitriptan for relieving the
symptoms of migraine
• Haloperidol may cause significant dystonic reactions. Midazolam is
preferable for managing severe agitated states8
• Promethazine has no place in the management of anaphylaxis as
it may cause hypotension and vasodilatation. Oral nonsedating
antihistamines are preferable for managing acute urticaria9
• Current emergency management guidelines do not include the use of
either procaine penicillin or terbutaline.
Emergency drugs not provided under the PBS
Doctors may obtain these as private items – at their own expense – by
submitting a written order to a pharmacist. In addition to the non-PBS
items listed in Table 2, the following should be considered:
• oral drugs: analgesics, antibiotics, prednisolone, diazepam
• normal saline, 1 L bags
• normal saline and water for injection.
Oxygen
References
1.
Adult cardiorespiratory arrest flow chart, Australian Resuscitation Council. Available
at www.resus.org.au/public/arc_adult_cardiorespiratory_arrest.pdf [Accessed 19
December 2007].
2. Emergency management of anaphylaxis in the community. Australian Prescriber
2007;30:115. Available at www.australianprescriber.com/upload/pdf/articles/913.
pdf [Accessed 19 December 2007].
3. National Asthma Council. Emergency management of asthma. Available at www.
nationalasthma.org.au/html/emergency/print/EMAC.pdf [Accessed 19 December
2007].
4. McKenzie DK, Abramson M, Crockett AJ, et al, The COPD-X Plan. Australian and
New Zealand guidelines for the management of chronic obstructive pulmonary
disease, 2007.
5. National Heart Foundation. Algorithm for the management of acute coronary syndrome. Available at www.heartfoundation.com.au/downloads/NHF_ACS_chart0506.
pdf [Accessed 19 December 2007].
6. Clark SFJ, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope.
Emerg Med J 2005;22:612–6.
7. Seidel R, Sanderson C, Mitchell G, Currow DC. Until the chemist opens – palliation
from the doctor’s bag. Aust Fam Physician 2006;35:225–31.
8. Pharmaceutical Benefits Scheme: Doctors bag emergency drugs. Available at www.
pbs.gov.au/html/healthpro/browseby/doctorsbag [Accessed 19 December 2007].
9. Brown SGA, Mullins RJ, Gold MS. Anaphylaxis: diagnosis and management. Med J
Aust 2006;185:283–9.
10. Hiramanek N, O’Shea C, Lee C, Speechly C, Cavanagh K. What’s in the doctor’s bag?
Aust Fam Physician 2004;33:714–20.
Oxygen is essential for managing emergencies and its availability is a
requirement for general practice accreditation. Oxygen cylinders can
be hired and refilled from a medical gas supplier (eg. BOC). A size C
cylinder (490 L) will last for 55 minutes at 8 L/min.
The following are required to administer oxygen: adult and paediatric
Hudson masks and nebuliser masks, nasal prongs, airways, and a bagvalve-mask breathing system (eg. Air Viva 3).
Equipment for managing emergencies
Appropriate supplies of IV infusion sets, cannulas, syringes, and needles
are required. General practitioners should consider the following items
for their practices:
• an automated external defibrillator (AED) with monitor and manual
override. Although a defibrillator is not a requirement for practice
accreditation, its absence may put a practice at clinical and
medicolegal risk
• pulse oximeter
• portable packs to enable equipment to be taken for use offsite.
Equipment for the doctor’s bag is discussed in detail by Hiramanek
et al.10
Managing emergency drugs in general practice
Drugs must be stored in a locked cupboard or a locked bag at less than
25°C. ADT and syntometrine are stored in a refrigerator. Schedule 8
drugs (opioids) must be stored in a locked, fixed, steel safe; although
ampoules may be put in a locked bag for use away from the clinic.
All emergency drugs should be logged in a book or spreadsheet that
includes date received, date administered, recipient, and expiry date.
Systems should be in place for checking drug stocks and expiry dates,
and for auditing the log.
A separate book is required to log Schedule 8 drugs received and
used. A Schedule 8 drug record book is available from The Royal
Australian College of General Practitioners at www.racgp.org.au/
publications/recordkeeping.
Conflict of interest: none declared.
546 Reprinted from AUSTRALIAN FAMILY PHYSICIAN Vol. 37, No. 7, July 2008
CORRESPONDENCE afp@racgp.org.au
VOLUME 35 : NUMBER 1 : FEBRUARY 2012
FEATURE
Emergency drug doses –
PBS* doctor’s bag items
DRUG
INDICATION
DOSE
Adrenaline
(1000 microgram in 1 mL
injection equivalent to
1:1000)
Anaphylaxis
1
5–10 microgram/kg IM approximates to:
Adults:
<50 kg
>50 kg
0.25−0.5 mL
0.5 mL
Children: 10 kg (1–2 years) 0.1 mL
15 kg (2–3 years) 0.15 mL
20 kg (4–6 years) 0.2 mL
30 kg (7–10 years) 0.3 mL
1000 microgram = 1 mg
Repeat dose every 5 minutes if no response
Cardiac arrest
Adults: 0.5−1 mg IV
Flush with normal saline to aid entry into the circulation
Children: 10 microgram/kg slow IV
(Dilute 1 mL adrenaline injection 1:1000 with 9 mL sodium chloride (0.9%) and
give 0.1 mL/kg)
Atropine
(0.6 mg in 1 mL injection)
Severe bradycardia,
asystole
Adults: 1 mg IV, repeat every 3−5 minutes until desired heart rate is reached or
to a maximum of 3 mg
Children: 20 microgram/kg IV (maximum dose 0.5 mg), repeat every 5 minutes
until desired heart rate is reached or to a total maximum of 1 mg
Benztropine
(2 mg in 2 mL injection)
Acute dystonic reactions
Adults: 1−2 mg IM or IV
Benzylpenicillin
(600 mg or 3 g powder,
dissolve in water for
injections)
Severe infections, including Adults and children 10 years: 1.2 g IV or IM
suspected meningococcal
Children aged 1−9 years: 600 mg IV or IM
disease
Children <1 year: 300 mg IV or IM
Chlorpromazine
(50 mg in 2 mL injection)
Acute psychosis, severe
behavioural disturbance
Children >3 years: 20 microgram/kg IM or IV (maximum 1 mg). Repeat after
15 minutes if needed.
Avoid parenteral use – injections cause pain and skin irritation. Use haloperidol
instead.
Adults: If there is no alternative, chlorpromazine 25−50 mg (12.5−25 mg in the
elderly) can be given by deep IM injection (buttock or deltoid)
Dexamethasone sodium
phosphate
(4 mg in 1 mL injection)
Acute severe asthma2
Adults: 4−12 mg IV slowly
Severe croup
Children: 0.15 mg/kg IM if oral route is not possible
Bacterial meningitis
Start before or at the same time as antibiotic
Adults: 10 mg IV
Children aged >3 months: 0.15 mg/kg IV
Diazepam
(10 mg in 2 mL injection)
Severely disturbed patients Adults: 5−10 mg IV over 1−2 minutes (halve dose in elderly) in a large vein.
Repeat if necessary every 5−10 minutes (maximum 30 mg).
Seizures
Adults: 10 mg IV slowly in a large vein. Repeat once if necessary.
10–20 mg rectally if IV access not possible. Repeat once if necessary.
Children: 0.2−0.3 mg/kg IV slowly in a large vein (maximum 10 mg). Repeat
once if necessary.
0.3−0.5 mg/kg rectally (maximum 10 mg). Repeat once if necessary.
Dihydroergotamine
(1 mg in 1 mL injection)
Severe migraine
Adults: 0.5−1 mg SC or IM. Repeat every hour if needed (maximum 3 mg daily).
* Pharmaceutical Benefits Scheme
Full text free online at www.australianprescriber.com
25
VOLUME 35 : NUMBER 1 : FEBRUARY 2012
Emergency drug doses – PBS doctor’s bag items
FEATURE
DRUG
INDICATION
DOSE
Diphtheria and tetanus
booster vaccine
(0.5 mL pre-filled syringe)
Tetanus prophylaxis
Adults and children >8 years: 0.5 mL IM
Frusemide
(20 mg in 2 mL injection)
Left ventricular failure,
acute pulmonary oedema
Adults: 20−40 mg IV slowly or IM
Glucagon
(injection kit containing
1 mg glucagon and 1 mL
solvent in syringe)
Severe hypoglycaemia
Adults and children >5 years: 1 mg SC, IM or IV
Glyceryl trinitrate
(400 microgram per dose,
200 doses as sublingual
spray)
Acute angina, acute left
ventricular failure
Adults: 1−2 sprays under the tongue. Repeat after 5 minutes if needed
(maximum 3 sprays).
Haloperidol
(5 mg in 1 mL injection)
Acute psychosis, severe
behavioural disturbance
Adults: 2−10 mg IM (0.5−2 mg in the elderly)
Hydrocortisone sodium
succinate
(100 mg or 250 mg with
2 mL solvent for injection)
Acute severe asthma
Adults: 100 mg IV
Children: 4 mg/kg IV
Anaphylaxis
Adults: 100 mg IV or IM
Children: 2−4 mg/kg IV
Acute adrenal insufficiency
Adults: 100 mg IV or IM
Children 1–12 years: 50 mg IV or IM
Children 1–12 months: 25 mg IV or IM
Sustained ventricular
tachycardia
Lignocaine has serious adverse effects including the potential to worsen
arrhythmia and cardiac failure. Do not use outside of hospital.
Lignocaine
(100 mg in 5 mL injection)
Children <5 years: 0.5 mg SC, IM or IV
Adults and children: 1 mg/kg IV over 1−2 minutes. Repeat after 5 minutes if
needed.
Metoclopramide
(10 mg in 2 mL injection)
Nausea and vomiting
Adults: IV or IM
>60 kg
10 mg starting dose
30−59 kg 5 mg starting dose
(maximum 0.5 mg/kg daily)
Not generally recommended in children as there is a risk of extrapyramidal
adverse effects
Methoxyflurane
(3 mL plus inhaler)
Pain after acute trauma
Adults and children (who are able to use the device, usually
6–8 breaths at a time (maximum 6 mL/day)
Morphine sulfate
(15 mg or 30 mg in 1 mL
injection)
Severe pain
Adults: SC or IM starting at lower dose
<39 years
40−59 years
60−69 years
70−85 years
>85 years
5 years):
7.5−12.5 mg
5−10 mg
2.5−7.5 mg
2.5−5 mg
2−3 mg
Can also be given as IV increments of 0.5−2 mg titrated to effect
Children >1 year and <50 kg: 0.05−0.1 mg/kg SC or IM
Naloxone
(2 mg in 5 mL injection)
Opioid overdose
Procaine penicillin
(1.5 mg in 3.4 mL injection)
Severe infections (only
suitable for infections
where prolonged low
concentrations are
appropriate)
This should read
(1.5 g in 3.4 mL injection)
Corrected May 2013
26
Adults and children: 0.4−0.8 mg IV, IM or SC repeated as necessary
Neonates born with low APGAR scores to mothers taking opioids:
0.1 mg/kg IV, IM or SC. Repeat if needed.
Adults: 1−1.5 g by deep IM injection
Children: 50 mg/kg by deep IM injection
Full text free online at www.australianprescriber.com
VOLUME 35 : NUMBER 1 : FEBRUARY 2012
FEATURE
DRUG
INDICATION
DOSE
Prochlorperazine
(12.5 mg in 1 mL injection)
Nausea and vomiting,
vertigo
Adults: 12.5 mg IM or IV
Promethazine
hydrochloride
(50 mg in 2 mL injection)
Allergic reactions
Adults and children >12 years: 25−50 mg IM
Children >2 years: 0.125 mg/kg IM
Nausea and vomiting
Adults and children >12 years: 12.5−25 mg IM
Salbutamol inhaler
(100 microgram per dose,
200 doses)
Acute asthma,
bronchospasm
Adults and children: 4 puffs (400 microgram) via spacer. Repeat after 4
minutes if needed. If still no improvement, continue giving 4 puffs every 4
minutes until ambulance arrives.
Salbutamol nebuliser
solution
(2.5 mg or 5 mg in 2.5 mL
per dose, 30 doses)
Acute asthma,
bronchospasm
Adults and children >2 years: 2.5−5 mg by nebuliser as required
Terbutaline
(500 microgram in 1 mL
injection)
Acute asthma
Tramadol
(100 mg in 2 mL injection)
Pain
Verapamil
(5 mg in 2 mL injection)
Paroxysmal
Do not use outside of hospital
supraventricular
Adults: 5 mg IV slowly (over at least 3 minutes), repeat after 5–10 minutes
tachycardia in patients who
if no response
are not:
Children: 0.1−0.3 mg/kg IV, repeat after 30 minutes if no response
- taking beta blockers
(maximum 5 mg)
- having an infarction
Children <2 years: 0.1 mg/kg up to 2.5 mg by nebuliser as required
For anaphylaxis give 5 mg by nebuliser to adults and children, repeat if
required
Adults: 250 microgram SC
Children: 5 microgram/kg SC
Adults: 50−100 mg IV over 2–3 minutes or IM
- in second or third degree
atrioventricular block
* Pharmaceutical Benefits Scheme
IM intramuscular
IV intravenous
A guide to paediatric weights
SC subcutaneous
10 kg at 1–2 years
15 kg at 2–3 years
20 kg at 4–6 years
30 kg at 7–10 years
PBS* doctor’s bag items for palliative care patients
These drugs should only be used after consultation with a palliative care specialist
DRUG
INDICATION
DOSE
Clonazepam
(oral liquid containing
25 mg in 10 mL)
Preventing seizures, hiccups
Adults: 0.25–1 mg orally or sublingually
Hyoscine butylbromide
(20 mg in 1 mL injection)
Noisy breathing and
secretions
Adults: 10–20 mg subcutaneously
* Pharmaceutical Benefits Scheme
Acknowledgement: Australian Prescriber thanks the staff at the Australian Medicines Handbook for their help in preparing this chart.
REFERENCES
1.
Anaphylaxis: emergency
management for health professionals
[wall chart]. Aust Prescr 2011;34:124.
www.australianprescriber.com/
magazine/34/4/artid/1210
FURTHER READING
2.
National Asthma Council Australia.
Asthma Management Handbook
2006.
www.nationalasthma.org.au/
handbook
Holmes JL. Time to restock the
doctor’s bag.
Aust Prescr 2012;35:7–9.
Baird A. Drugs for the doctor’s bag.
Aust Prescr 2007;30:143-6.
Full text free online at www.australianprescriber.com
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