Emergency Medical Technician Medication Formulary PDF

APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Medication Formulary for Emergency Medical Technician The Medication Formulary is published by the Pre-Hospital Emergency Care Council (PHECC) to enable pre-hospital emergency care practiti...

APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Medication Formulary for Emergency Medical Technician The Medication Formulary is published by the Pre-Hospital Emergency Care Council (PHECC) to enable pre-hospital emergency care practitioners to be competent in the use of medications permitted under Medicinal Products 7th Schedule (SI 177 of 2021). This is a summary document only and practitioners are advised to consult with official publications to obtain detailed information about the medications used. The Medication Formulary is recommended by the Medical Advisory Committee (MAC) prior to publication by Council. The medications herein may be administered provided: 1. The practitioner is in good standing on the PHECC practitioner’s Register. 2. The practitioner complies with the Clinical Practice Guidelines (CPGs) published by PHECC. 3. The practitioner is acting on behalf of an organisation (paid or voluntary) that is a PHECC licensed CPG provider. 4. The practitioner is privileged, by the organisation on whose behalf he/she is acting, to administer the medications. 5. The practitioner has received training on, and is competent in, the administration of the medication. 6. The medications are listed on the Medicinal Products 7th Schedule. The context for administration of the medications listed here is outlined in the CPGs. Every effort has been made to ensure accuracy of the medication doses herein. The dose specified on the relevant CPG shall be the definitive dose in relation to practitioner administration of medications. The principle of titrating the dose to the desired effect shall be applied. The onus rests on the practitioner to ensure that he/she is using the latest versions of CPGs which are available on the PHECC website www.phecc.ie Sodium Chloride 0.9% (NaCl) is the IV/IO fluid of choice for pre-hospital emergency care. Water for injection shall be used when diluting medications, however if not available NaCl (0.9%) may be used if not contraindicated. All medication doses for patients ≤ 15 years shall be calculated on a weight basis unless an age- related dose is specified for that medication. The route of administration should be appropriate to the patient’s clinical presentation. IO access is authorised for advanced paramedics for life threatening emergencies (or under medical direction). 95 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN The dose for paediatric patients may never exceed the adult dose. Approved Paediatric weight estimations are: Neonate = 3.5 Kg Six months = 6 Kg One to five years = (age x 2) + 8 Kg Greater than 5 years = (age x 3) + 7 Kg Pregnancy caution: Medications should be prescribed in pregnancy only if the expected benefit to the mother is thought to be greater than the risk to the foetus, and all medications should be avoided, if possible, during the first trimester. PHECC practitioners therefore should avoid using medications in early pregnancy unless absolutely essential and where possible medical advice should be sought prior to administration. Paramedic authorisation for IV infusion continuation PHECC registered paramedics are authorised to continue an established IV infusion in the absence of an advanced paramedic or doctor during transportation. Medication Formulary Age Designations Index of medication formulary (Adult ≥ 16 and Paediatric ≤ 15 unless otherwise stated) This version contains 14 medications. Please visit www.phecc.ie for the latest edition/version Amendments to the Emergency Medical Technician 2017 Edition: New Medications introduced: Activated Charcoal 96 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Changes to Monographs for June 2023 updates to CPG 2021 CHLORPHENAMINE Heading Add Delete Classification Sedating Antihistamine – H1 receptor antagonist. Sedating Antihistamine – H2 receptor antagonist. IBUPROFEN Heading Add Delete Contra-indications suspected or confirmed chicken pox. Additional information Ibuprofen should not be administered to children with a suspected or confirmed chicken pox diagnosis. NITROUS OXIDE 50% AND OXYGEN 50% (ENTONOX®) Heading Add Delete Contra-indications Bullous Emphysema/ Middle Ear Procedures/ Following a recent dive/ Recent eye surgery involving bubble gas insertion/ Head injury/ Conditions where air is trapped in the body and expansion would be dangerous/ Maxillo-facial injuries/ Sedation or intoxication. 97 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Changes and updates for CPG 2021 Changes to Monographs 1. Class and Description headings have merged to one Classification heading in line with BNF drug descriptors 2. Long term side effects have been removed unless essential 3. Pharmacology/Action has been removed unless essential information EPINEPHRINE (1:1,000) CHANGES TO ADRENALINE (1:1000) Heading Add Delete Medication Adrenaline 1:1000. Epinephrine 1:1000. Indications Stridor, Symptomatic Bradycardia and Cardiogenic Shock. Contra-indications Hypersensitivity to excipients. Usual Dosages < 6 months 10 mcg/kg IM All dosing which was previously recommended 6 months to < 6 years 150 mcg (0.15 mL IM) under the following age ≥ 6 years to < 12 years 300 mcg (0.3 mL IM) categories ≥ 12 years 300 mcg (0.3 mL) (if child < 6 months, 6 months to 5 small or prepubital) or 500 years, 6 to 8 years, (0.5 mL IM) > 8 years. 98 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN ASPIRIN Heading Add Delete Classification Merge Class and Description to Class. Classification: Antithrombotic – Description. Antiplatelet Drug which reduces clot formation. Description Anti-inflammatory agent and an inhibitor of platelet function. Useful agent in the treatment of various thromboembolic diseases such as acute myocardial infarction. Pharmacology/ Antithrombotic: Action Inhibits the formation of thromboxane A2, which stimulates platelet aggregation and artery constriction. This reduces clot/thrombus formation in an MI. Long term Generally mild and infrequent but incidence side-effects of gastro-intestinal irritation with slight asymptomatic blood loss, increased bleeding time, bronchospasm and skin reaction in hypersensitive patients. 99 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN CHLORPHENAMINE Heading Add Delete Classification Sedating antihistamine – H2 receptor antagonists. Class: Antihistamine. Description: H1 antagonist to counteract the effects of histamine release. Usual dosages For IV route, administer over 1 minute. May dilute with Removal of all existing Sodium Chloride 0.9% for convenient administration volume paediatric dosing. of small doses. Severity Age Dose and route of administration Mild 6 to 11 years 2 mg PO (EMT / P / AP) ≥ 12 years 4 mg PO (EMT / P / AP) Moderate 1 month – 6 months 0.25 mg/kg IM (EMT / P) or 0.25 mg/kg IV (AP) >6 months - < 6 years 2.5 mg IM (EMT / P) or 2.5 mg IV (AP) 6 to < 12 years 2 mg PO or 5 mg IM (EMT / P) or 5 mg IV (AP). ≥ 12 years 4 mg PO or 10 mg IM (EMT / P) or 10 mg IV (AP) Severe 1 month - 6 months - 1 month < 1 year - 90 mg PR. > 1 month < 1 year - 80 mg PR. Side effects Long term side-effects. SALBUTAMOL Heading Add Delete Classification Beta-2 Adrenoceptor agonist Class: Sympathetic agonist. selective – short acting. Description: Sympathomimetic that is selective for Beta-2 Adrenergic receptors. Presentation 100 mcg. 0.1 mg. Usual Dosages 100 mcg metered aerosol spray. 0.1 mg metered aerosol spray. Pharmacology / Action Remove text/section Beta-2 agonist/ Bronchodilation/ relaxation of smooth muscle. 103 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EMT P AP MEDICATION ACTIVATED CHARCOAL Classification Antidotes and Chelators – Intestinal adsorbents: reduction of absorption of poisons in the GI system / active elimination of poisons. Presentation Activated charcoal granules for suspension. Administration Oral suspension (PO). (CPG: 6.10.2). Indications Emergency treatment of acute oral poisoning or drug overdose. Contra-Indications Although activated charcoal is not contraindicated in poisoning by strong acids and alkalis and other corrosive substances, its value as a detoxicant for these substances is limited. Activated Charcoal is poor in binding cyanide, iron salts and some solvents including methanol, ethanol and ethylene glycol. Usual Dosages Adult: 50g PO. Reconstitute with water as directed by manufacturer. The reconstituted product should be taken immediately. Repeat as necessary. Paediatric: Not Indicated. Side effects Bezoar/ Constipation/ diarrhoea/ GI disorders/ Black stools. Caution: aspiration may lead to airway obstruction. Additional May be mixed with soft drinks or fruit juice for ease of administration & to mask the information taste. Substances which may be absorbed by Activated charcoal (but are not limited to) include: Aspirin & salicylates/ Barbiturates/ Benzodiazepines/ Chlormethiazole/ Chloroquine/ Chlorpromazine & related phenothiazines/ Clonidine/ Cocaine and other stimulants/ Digoxin and digitoxin/ Ibuprofen/ Mefenamic acid/ Mianserin/ Nicotine/ Paracetamol/ Paraquat/ Phenelzine and other MAOIs/ Phenytoin/ Propranolol and other Beta Blockers/ Quinine/ Theophylline/ Zidovudine. 104 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EFR EMT P AP MEDICATION ADRENALINE (1:1,000) Classification Sympathetic agonist, Sympathomimetic – Vasoconstrictor. Acts on both alpha & beta receptors and increases both heart rate and contractility. It can cause peripheral vasodilation (beta) or vasoconstriction (alpha). Presentation Pre-filled syringe, ampoule or Auto injector. 1 mg/1 mL (1:1,000). Administration Intramuscular (IM), Intravenous (IV) and Nebulisation (Neb). (CPG: 2/3.10.1 2/3.13.21, 4/5/6.3.2, 4/5/6.10.1, 4/5/6.11.1, 4/5/6.13.9, 5/6.13.20. 4/5/6.13.21, 5/6.14.6) Indications Severe allergic reaction/ anaphylaxis, Stridor, Symptomatic Bradycardia and Cardiogenic shock. Contra-Indications Hypersensitivity to excipients. Usual Dosages Adult: Anaphylaxis 500 mcg IM (0.5 mL of 1: 1,000). EFR assist patient – 0.3 mg (Auto injector). (Repeat every 5 minutes PRN). Adult: Symptomatic Bradycardia / Cardiogenic shock (AP): 10 mcg IV/IO (Repeat PRN). (Dilute 1 mg Adrenaline in 100 mL NaCl and draw up in 1 mL syringe, administer the dose over 1 minute). (Off-license). Anaphylaxis Paediatric: < 6 months 10 mcg/kg IM 6 months to < 6 years 150 mcg (0.15 mL IM) ≥ 6 years to < 12 years 300 mcg (0.3 mL IM) ≥ 12 years 300 mcg (0.3 mL) (if child small or prepubital) or 500 mcg (0.5 mL IM) EFR assist patient – 6 months < 10 years: 0.15 mg (Auto injector) (Repeat every 5 minutes PRN). ≥ 10 years: 0.3 mg (Auto injector) (Repeat every 5 minutes PRN). Stridor (P/ AP): < 1 Year: 2.5 mg NEB. ≥ 1 year: 5 mg NEB (Repeat after 30 minutes PRN). Sepsis (AP): Adrenaline 0.1 mcg/kg IV/IO. Side effects Palpitations / Tachyarrhythmias / Hypertension / Angina-like symptoms. 105 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: CFR FAR EFR EMT P AP MEDICATION ASPIRIN Classification Antithrombotic – Antiplatelet Drug which reduces clot formation. Presentation 300 mg dispersible tablet. 300 mg Enteric Coated (EC) tablet. Administration Orally (PO) - dispersed in water, or to be chewed if not dispersible form. (CPG: 5/6.3.1, 4.3.1, 1/2/3.3.1). Indications Cardiac chest pain or suspected myocardial infarction. Management of unstable angina and non ST-segment elevation myocardial infarction (NSTEMI). Management of ST-segment elevation myocardial infarction (STEMI). Contra-Indications Active symptomatic gastrointestinal (GI) ulcer/ Bleeding disorder (e.g. haemophilia)/ Known severe adverse reaction/ Patients < 16 years old (risk of Reye’s Syndrome). Usual Dosages Adult: Anaphylaxis 300 mg Tablet. Paediatric: Contraindicated. Side effects Epigastric pain and discomfort/ Bronchospasm/ Gastrointestinal haemorrhage/ Increased bleeding times/ skin reactions in hypersensitive patients. Additional Aspirin 300 mg is indicated for cardiac chest pain, regardless if patient is on an information anti-coagulant or is already on Aspirin. If the patient has swallowed Aspirin EC (enteric coated) preparation without chewing, the patient should be regarded as not having taken any Aspirin; administer 300 mg PO. 106 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EMT P AP MEDICATION CHLORPHENAMINE Classification Sedating Antihistamine – H1 receptor antagonist. Presentation 10 mg in 1 mL ampoule. 4 mg tablet. Administration Intravenous (IV), Intramuscular (IM) and Orally (PO). (CPG: 4/5/6.10.1, 4/5/6.13.21). Indications Anaphylaxis or allergic reaction. Contra-Indications Known severe adverse reaction/ Pre-coma states. Usual Dosages For IV route, administer over 1 minute IV: May dilute with Sodium Chloride 0.9% for convenient administration volume of small doses. Adult: Allergic reaction Mild: 4 mg PO (EMT / P / AP). Moderate: 4 mg PO or 10 mg IM (EMT / P) or 10 mg IV (AP). Severe/Anaphylaxis: 10 mg IM (EMT / P) or 10 mg IV (AP). Paediatric: Severity Age Dose and route of administration Mild 6 to 11 years 2 mg PO (EMT/ P/ AP) ≥ 12 years 4 mg PO (EMT/ P /AP) Moderate 1 month - 6 months 0.25 mg/kg IM (EMT/ P) or 0.25 mg/kg IV (AP) > 6 months - < 6 years 2.5 mg IM (EMT/ P) or 2.5 mg IV (AP) 6 to < 12 years 2 mg PO or 5 mg IM (EMT/ P) or 5 mg IV (AP). ≥ 12 years 4 mg PO or 10 mg IM (EMT/ P) or 10 mg IV (AP) Severe 1 month - 6 months 0.25 mg/kg IM (EMT/ P) or 0.25 mg/kg IV (AP) > 6 months - < 6 years 2.5 mg IM (EMT/ P) or 2.5 mg IV (AP) 6 to < 12 years 5 mg IM (EMT/ P) or 5 mg IV (AP) ≥ 12 years 10 mg IM (EMT/ P) or 10 mg IV (AP Side effects Causes drowsiness, do not drive or operate machinery. Additional Use with caution in epilepsy/ Prostatic hypertrophy/ Glaucoma/ Hepatic disease/ information Bronchitis/ Bronchiectasis/ Thyrotoxicosis/ Raised intra-ocular pressure/ Severe hypertension/ Cardiovascular disease/ Bronchial asthma. 107 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EMT P AP MEDICATION GLUCAGON Classification Hypoglycaemia: Glycogenolytic Hormones. Presentation 1 mg vial powder and solution for reconstitution (1 mL). Administration Intramuscular (IM). (CPG: 4/5/6.5.3, 4/5/6.13.11). Indications Hypoglycaemia in patients unable to take oral glucose or unable to gain IV access, with a blood glucose level < 4 mmol/L. Contra-Indications < 1 month/ Phaechromocytoma/ Known Severe Adverse Reactions Usual Dosages Adult: 1 mg IM. Paediatric: ≥ 1 month and < 25kg: 500 mcg IM. ≥ 1 month and ≥ 25kg: 1 mg IM. Side effects Common: Nausea. Uncommon: Vomiting. Rare: may cause Hypotension/ Dizziness/ Headache. Additional May be ineffective in patients with low stored glycogen e.g. prior use in previous information 24 hours, alcohol dependent patients with liver disease. Store in refrigerator. Stable at room temperature for 18 months, use immediately once reconstituted. Protect from light. Hypoglycaemic paediatric patients who are not diagnosed as diabetic should not be administered Glucagon. (this does not preclude the administration of glucose gel or glucose solution to treat hypoglycaemia). 108 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EFR EMT P AP MEDICATION GLUCOSE GEL Classification Nutrients. Sugars: Antihypoglycaemic. Presentation Glucose gel in a tube or sachet. Administration Buccal administration: Administer gel to the inside of the patient’s cheek and gently massage the outside of the cheek. (CPG: 4/5/6.5.3, 4/5/6.12.7 4/5/6.13.11). Indications Hypoglycaemia. Blood glucose < 4 mmol/L. Contra-Indications Known severe adverse reaction. Usual Dosages Adult: 10 – 20 g buccal (Recheck blood glucose and repeat after 15 min if required). Paediatric: New-born neonate 2 - 4 mL if blood glucose ≤ 2.6 mmol/L. ≤ 8 years 5 – 10 g buccal (recheck blood glucose and repeat after 15 mins if required). > 8 years 10 – 20 g buccal (recheck blood glucose and repeat after 15 mins if required). Side effects May cause vomiting in patients under the age of 5 years if administered too quickly. Additional Glucose gel will maintain glucose levels once raised but should be used secondary information to Dextrose to reverse hypoglycaemia. Proceed with caution: Patients with airway compromise. Altered level of consciousness. 109 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EFR EMT P AP MEDICATION GLYCERYL TRINITRATE (GTN) Classification Nitrate. Potent coronary vasodilator/ reduces BP/ Dilation of systemic veins. Presentation Aerosol spray: Metered dose of 400 mcg. Administration Sublingual: Hold the pump spray vertically with the valve head uppermost. Place as close to the mouth as possible and spray under the tongue. The mouth should be closed immediately after each dose. (CPG: 4/5/6.2.6, 4/5/6.3.1, 1/2/3.3.1). Indications Angina/ suspected myocardial infarction (MI). EFR: may assist with administration. EMT: Angina/ suspected myocardial infarction (MI) with systolic BP ≥110 mmHg. Advanced Paramedics and Paramedics - Pulmonary oedema Contra-Indications SBP < 90 mmHg/ Viagra or other phosphodiesterase type 5 inhibitors (Sildenafil, Tadalafil and Vardenafil) used within previous 24 hours/ Severe mitral stenosis/ Known severe adverse reaction. Usual Dosages Adult: Angina or MI: 400 mcg sublingual. (Repeat at 3-5 min intervals, Max: 1200 mcg). EFR: assist administration - 400 mcg sublingual max. Pulmonary oedema: 800 mcg/ 2 sprays (repeat x 1 PRN) (P & AP). Paediatric: Not indicated. Side effects Headache/ Transient Hypotension/ Flushing/ Dizziness. Additional Caution with inferior wall MI with right ventricular involvement as this may lead to information profound hypotension. If the pump is new or it has not been used for a week or more the first spray should be released into the air. 110 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EMT P AP MEDICATION IBUPROFEN Classification Analgesics: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Pain and Inflammation in musculoskeletal disorders. Presentation Suspension 100 mg in 5 mL and 200 mg in 5 mL. 200 mg, 400 mg tablets. Administration Orally (PO). (CPG: 4/5/6.6.2, 4/5/6.13.13). Indications Mild to moderate pain. Contra-Indications Not suitable for children under 3 months (or body weight < 5kg)/ Patient with history of asthma exacerbated by Aspirin/ Pregnancy/ Peptic ulcer disease/ Known renal failure/ Known severe liver failure/ Known severe heart failure/ Concurrent NSAID use (e.g. Diclofenac, Naproxen)/ Known severe adverse reaction / suspected or confirmed chicken pox. Usual Dosages Adult: 400 mg PO (Mild pain). 600 mg PO (Moderate pain). Paediatric: 10 mg/kg PO to a maximum of 400 mg. Side effects Skin rashes/ Gastrointestinal intolerance and bleeding. Additional If Ibuprofen administered in previous 6 hours, adjust the dose downward by the information amount given by other sources resulting in a maximum of 10 mg/kg or 400 mg for paediatrics. Caution with significant burns or poor perfusion due to risk of kidney failure. Caution if on oral anticoagulant (e.g. Warfarin, Rivaroxaban, Apixaban, Edoxaban) due to increased bleeding risk. Ibuprofen may be combined with Paracetamol for synergic effect. Ibuprofen should not be administered to children with a suspected or confirmed chicken pox diagnosis. 111 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EMT P AP MEDICATION METHOXYFLURANE Classification Anaesthetics. General: Volatile anaesthetic agent. Presentation 3 mL vial with a tear off tamper-evident seal which is administered via carbon inhalation vapouriser. Administration Inhaled (INH) through an activated Carbon Chamber (self-administered). (CPG: 4/5/6.6.2, 4/5/6.13.13). Indications Adult: Moderate to severe pain. Paediatric: Moderate to severe pain. Contra-Indications < 5 years old Altered LOC due to head injury, drugs or alcohol/ Cardiovascular instability/ Respiratory depression/ Renal Failure or Impairment/ Known Severe Adverse Reactions/ Malignant Hyperthermia. Usual Dosages Adult: 3 mL (INH) (repeat x 1 only PRN). Paediatric: 3 mL (INH) (repeat x 1 only PRN). Side effects Amnesia/ Anxiety/ Depression/ Dizziness/ Dysarthria/ Dysgeusia/ Euphoria/ Headache/ Sensory neuropathy/ Somnolence/ Hypotension/ Coughing/ Dry mouth/ Nausea/ Feeling drunk/ Sweating. Uncommon: Tingling or numbness to hands and feet/ Tiredness/ Mouth discomfort. Additional Patients with pain due to acute coronary syndrome (ACS) or migraine may not be information suitable for Methoxyflurane. Methoxyflurane crosses the placenta. Consider the risk of central nervous system (CNS) and respiratory depression in an already compromised foetus. Methoxyflurane has a mildly pungent odour. If used in a confined space request the patient to inhale and exhale through the inhaler tube while ensuring that the activated Carbon Chamber is attached. 112 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EMT P AP MEDICATION NALOXONE Classification Opioid toxicity: Opioid receptor antagonist. The management and reversal of opiate overdose. Presentation Ampoules 400 mcg/mL (0.4 mg in 1 mL) / Minijet syringe. Administration IV / IO / IM / SC / IN. (CPG: 6.10.2, 4/5/6.12.7, 4/5/6.13.7 4/5/6.14.6). Indications Inadequate respiration and/or ALoC following known or suspected narcotic overdose. Contra-Indications Known severe adverse reaction. Usual Dosages Adult: 400 mcg IV/IO (AP) (repeat after 3 min PRN to a Max dose of 2 mg). 400 mcg IM/SC (P) (repeat after 3 min PRN to a Max dose of 2 mg). 800 mcg IN (EMT) (repeat x 1 after 3 min PRN). Paediatric: 10 mcg/kg IV/IO (AP). 10 mcg/kg IM/SC (P). 20 mcg/kg IN (EMT). (Repeat dose PRN to maintain opioid reversal to Max 0.1 mg/kg or 2 mg). Side effects Acute reversal of narcotic effect ranging from nausea and vomiting to agitation and seizures. Additional Use with caution in pregnancy. information Administer with caution to patients who have taken large dose of narcotics or are physically dependent. Rapid reversal will precipitate acute withdrawal syndrome. Prepare to deal with aggressive patients. 113 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EMT P AP MEDICATION NITROUS OXIDE 50% AND OXYGEN 50% (ENTONOX®) Classification Analgesics – Volatile Liquid Anaesthetics - Potent analgesic gas contains a mixture of both Nitrous Oxide and Oxygen. Presentation Cylinder, coloured blue with white and blue triangles on cylinder shoulders. ED cylinder: White cylinder. Medical gas: 50% Nitrous Oxide & 50% Oxygen. Brand name: Entonox®. Administration Self-administered. Inhalation by demand valve with face-mask or mouthpiece. (CPG: 4/5/6.6.2, 4/5/6.12.3, 4/5/6.12.4, 4/5/6.13.13). Indications Moderate to severe pain. Contra-Indications Altered level of consciousness/ Chest Injury/ Pneumothorax/ Shock / Recent scuba dive/ Decompression sickness/ Intestinal obstruction/ Inhalation Injury/ Carbon monoxide (CO) poisoning/ Known severe adverse reaction/ Bullous Emphysema/ Middle Ear Procedures/ Following a recent dive/ Recent eye surgery involving bubble gas insertion/ Head injury/ Conditions where air is trapped in the body and expansion would be dangerous/ Maxillo-facial injuries/ Sedation or intoxication. Usual Dosages Adult and Paediatric: Self-administered until pain tolerable. Side effects Disinhibition/ Decreased level of consciousness/ Light headedness. Additional Caution should be issued before using Entonox with patients who have known information Chronic Obstructive Pulmonary Disease (COPD) or other conditions where compromised chemoreceptor sensitivity/function may be present. May cause respiratory depression and increases in PaCO2. Do not use if patient unable to understand instructions. In cold temperatures warm cylinder and invert at least 3 times to ensure mix of gases. Advanced paramedics may use discretion with minor chest injuries. Has an addictive property. Caution when using Entonox® for greater than one hour for sickle cell crisis. Prolonged or frequent use of ENTONOX may result in megaloblastic marrow changes, myeloneuropathy and sub-acute combined degeneration of the spinal cord. 114 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: CFR-A EFR EMT P AP MEDICATION OXYGEN Classification Gas. Presentation Medical gas: D, E or F cylinders, coloured black with white shoulders. (Please note: By 2025, all cylinders will be completely white with OXYGEN in black). CD cylinder: White cylinder. Administration Inhalation via: High concentration reservoir (non-rebreather) mask/ Simple face mask/ Venturi mask/ Tracheostomy mask/ Nasal cannulae/ CPAP device/ Bag Valve Mask. (CPG: Oxygen is used extensively throughout the CPGs). Indications Absent / Inadequate ventilation following an acute medical or traumatic event. SpO2 < 94% adults and < 96% paediatrics. SpO2 < 92% for patients with acute exacerbation of COPD. SpO2 < 90% for patients with acute onset of Pulmonary Oedema. Contra-Indications Bleomycin lung injury. Usual Dosages Adult: Cardiac and respiratory arrest or sickle cell crisis; 100%. Life threats identified during primary survey; 100% until a reliable SpO2 measurement obtained then titrate O2 to achieve SpO2 of 94% - 98%. For patients with acute exacerbation of COPD, administer O2 titrate to achieve SpO2 92% or as specified on COPD Oxygen Alert Card. All other acute medical and trauma titrate O2 to achieve SpO2 94% - 98%. Paediatric: Cardiac and respiratory arrest or sickle cell crisis; 100%. Life threats identified during primary survey; 100% until a reliable SpO2 measurement obtained then titrate O2 to achieve SpO2 of 96% - 98%. Neonatal resuscitation (< 4 weeks) consider supplemental O2 (≤ 30%). All other acute medical and trauma titrate O2 to achieve SpO2 of 96% - 98%. Side effects Prolonged use of O2 with chronic COPD patients may lead to reduction in ventilation stimulus. Additional Caution with emollients containing paraffin e.g. lip balms & moisurisers – may lead information to skin burns. A written record must be made of what oxygen therapy is given to every patient. Documentation recording oximetry measurements should state whether the patient is breathing air or a specified dose of supplemental Oxygen. Consider humidifier if oxygen therapy for paediatric patients is > 30 minutes duration. Caution with paraquat poisoning, administer Oxygen if SpO2 < 92%. Avoid naked flames, powerful oxidising agent. 115 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EMT P AP MEDICATION PARACETAMOL Classification Analgesic – Non-opioid. Presentation Rectal suppository 1 g, 500 mg, 250 mg, 180 mg, 125 mg, 80 mg. Suspension 120 mg in 5 mL or 250 mg in 5 mL. 500 mg tablet. Plastic vial, 1 g of Paracetamol in 100 mL solution for infusion, 500mg of paracetamol in 50 mL solution for infusion. Administration Per Rectum (PR). Orally (PO). IV infusion. (CPG: 4/5/6.6.2, 4/5/6.11.1, 4/5/6.13.13, 4/5/6.13.19, 5/6.13.20, 5/6.15.2). Indications Adult: Pyrexia/ Temperature > 38.3oC/ Mild or moderate pain. Paediatric: Pyrexia/ Temperature > 38.5oC/ Mild or moderate pain. Contra-Indications < 1 month old/ Known severe adverse reaction/ Chronic liver disease. Usual Dosages Adult: 1 g PO (EMT, P/AP). 1 g IV infusion (AP), if estimated weight < 50 kg, 15 mg/kg (administered slowly over 15 minutes). Palliative Care (P/AP): 1 g PO (Repeat after 4 – 6 hours x 1 PRN). Paediatric: PO (EMT, P/AP) PR (P/AP) IV Infusion (AP) (≥ 1 year Max 1 g) 15 mg/Kg PO > 1 month < 1 year - 80 mg PR < 1 year – 7.5 mg/kg IV slowly 1-3 years - 180 mg PR ≥ 1 year – 15 mg/kg IV slowly 4-8 years - 360 mg Side effects If Paracetamol IV is administered too fast it may result in hypotension. Additional Paracetamol is contained in Paracetamol suspension and other over the counter information drugs. Consult with parent / guardian in relation to medication administration prior to arrival on scene. For PR use be aware of the modesty of the patient, should be administered in the presence of a 2nd person. If Paracetamol administered in the previous 4 hours, adjust the dose downward by the amount given by other sources resulting in a maximum of 15 mg/Kg. Caution with IV Paracetamol in the absence of a buretrol. 116 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)  APPENDIX 1 - Medication Formulary EMERGENCY MEDICAL TECHNICIAN Clinical Level: EFR EMT P AP MEDICATION SALBUTAMOL Classification Beta-2 Adrenoceptor agonist selective – short acting. Presentation Nebule 2.5 mg in 2.5 mL. Nebule 5 mg in 2.5 mL. Aerosol inhaler: Metered dose 100mcg per actuation (Puff). Administration Nebule Inhalation via aerosol inhaler. (CPG: 4/5/6.2.4, 2/3.2.5, 4/5/6.2.5, 4/5/6.8.9, 2/3.10.1, 4/5/6.10.1, 2/3.13.8, 4/5/6.13.8, 2/3.13.21, 4/5/6.13.21, 6.17.7). Indications Bronchospasm/ Exacerbation of COPD/ Respiratory distress following submersion incident. Contra-Indications Known severe adverse reaction. Usual Dosages Adult: 5 mg NEB or 100 mcg metered aerosol spray (Repeat aerosol x 11). Repeat NEB at 5 minute intervals PRN EFR assist patient with Asthma/ Anaphylaxis. – 100 mcg metered aerosol spray (Repeat aerosol x 11 PRN). Paediatric: < 5 yrs - 2.5 mg NEB or 100 mcg metered aerosol spray (Repeat aerosol x 5). ≥ 5 yrs - 5 mg NEB or 100 mcg metered aerosol spray (Repeat aerosol x 11). (Repeat NEB at 5 minute intervals PRN). EFR: assist patient with Asthma/ Anaphylaxis – < 5 yrs - 100 mcg /1 actuation metered aerosol spray (Repeat aerosol x 5 PRN). ≥ 5 yrs - 100mcg / 1 actuation metered aerosol spray (Repeat aerosol x 11 PRN). Side effects Tachycardia/ Tremors/ Tachyarrhythmias/ High doses may cause Hypokalaemia. Additional It is more efficient to use a volumiser in conjunction with an aerosol inhaler when information administering Salbutamol. If an oxygen driven nebuliser is used to administer Salbutamol for a patient with acute exacerbation of COPD it should be limited to 6 minutes maximum. 117 Clinical Practice Guidelines - 2021 Edition (Updated June 2023)