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ILS PRACTITIONER PROTOCOLS

ACETYL SALICYLIC ACID

1.1

Acetyl Salicylic Acid ( AKA Aspirin)

Classification: Non-steroidal anti-inflammatory / platelet aggregation inhibitor

Schedule: 0
1.2

PharmaCOLOGY Action

Aspirin inhibits the enzyme cyclo-oxygenase thus inhibiting the production of prostaglandins including
thromboxane; it has no effect on leukotriene production.
Cyclo-oxygenase (COX), officially known as prostaglandin-endoperoxide synthase (PTGS), is an enzyme that
is responsible for formation of prostanoids, including prostaglandins, prostacyclin and thromboxane.
(They act in the formation of blood clots and reduce blood flow to the site of a clot.)
1.3

1.4

Adverse Effects

Anaphylactic reaction
o some patients, especially asthmatics exhibit notable sensitivity to aspirin, which may provoke
various hypersensitivity / allergic reactions
Potential bronchoconstriction in asthmatics
Gastric mucosa irritation
o dyspepsia; peptic ulceration; peptic bleeding
Bleeding tendency
Foetal distress due to obliteration of foetal ductus arteriosus
Suppression of uterine contractions
Indication

Suspected MI (Myocardial Infarction)

1.5

1.6

1.7

Contra Indication

Known hypersensitivity / allergy to aspirin

Peptic ulceration with active bleeding
Bleeding tendency
Patients already receiving Platelet Aggregation Inhibitors or Anticoagulants
Pregnancy
Children <12 years of age
Severe renal impairment/ renal transplant
No longer recommended in decompression sickness
Precautions

Bronchial asthma (aspirin-sensitive asthmatic)

Patient must be conscious
Packaging

Regular aspirin:
Extra strength:
Dispersible aspirin:
1.8

300mg tablet
500mg tablet
100mg & 300mg tablets

Administration and Dosages

Administer 150mg - 300mg orally, chewed, crushed, or dissolved

WARNING: Do not use high dose, such as full 500mg tablet. Do not use enteric coated aspirin.
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ACTIVATED CHARCOAL

2.1

Activated Charcoal

Classification: Carbon
Schedule: 1
2.2

PharmaCOLOGY

Study of properties & effects of drugs

Pharmacology effects:
Therapeutic Effects
Side Effects

(desirable)
(undesirable / harmful)

Activated Charcoal absorbs many poisonous compounds to its surface this reduces the absorption by the
GIT (Gastro-Intestinal Tract)
2.3

Adverse Effects

The patient may experience mild constipation

2.4

Indication

To assist in treatment of certain cases if overdoses and poisonings where agents/s have been orally ingested
(ONLY within an hours of ingestion)
2.5

Contra Indication

Should NOT be used with poisoning with:

Boric Acid
Cyanide
Ethanol
Ethylene Glycol
Lithium
Methanol
Organophosphates
Petroleum Products
Iron
Strong acids and Alkalis
When a pt. has decreased levels of consciousness or is unconscious
Unprotected airway
DO NOT USE if he container was not sealed properly
De-activation due to moisture exposure)
2.6

Packaging

Powder: Fine black powder in bottles of 25g and 50g

2.7

Dosage and Administration

Adult:
Paediatric:

1g / kg mixed with water, given orally

0.5g / kg mixed with water, given orally

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2 STIMULANTS

3.1

2 stimulants / Adrenergic Stimulants

ILS PRACTITIONER PROTOCOLS

Classification: Bronchodilators
Schedule:
2: Aerosol
3: Inhalant solutions and unit dose vials
3.2

3.3

PharmaCOLOGY Action

Fenoterol & Salbutamol are selective 2 stimulants acting on the 2 receptors in the lungs:
o bronchial smooth muscle: bronchodilation
At higher/repeated dosages, the systemic absorption progressively increases, thus acting on other
organs with 2 receptors e.g.
o Skeletal muscle : contraction
o Vascular smooth muscle : vasodilation
o Bladder smooth muscle : relaxation
o Intestinal smooth muscle : decreased peristalsis
o Uterine smooth muscle : tocolysis
o Glycogen stores : break down of glycogen to glucose
At higher/repeated dosages, the selectivity is also progressively lost and 1 effects (myocardium) are
experienced:
o Positive inotrope
o Positive chronotrope
o Positive dromotrope
o Increased myocardial oxygen consumption
Pharmaco-KINETICS

Onset of action : 5-15 minutes

Duration of action : 3-6 hours
3.4

3.5

3.6

3.7

3.8

Adverse Effects

Tremors, restlessness, anxiety, confusion, headache

Hypotension
Tachycardia, palpitations
Cramps
Nausea, vomiting
Urinary retention
Tocolysis
Hyperglycaemia
Hypokalaemia
Indication

Acute bronchospasm
Contra Indication

Known hypersensitivity / allergy to 2 stimulants

Neonates
Precautions

Special caution must be used when pulse rate exceeds 120 beats / minute
Packaging

Fenoterol:
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3.9

ILS PRACTITIONER PROTOCOLS

o Berotec aerosol: 100g

o Inhalant solution: 1mg/ml
o UDV: 1.25mg/2ml or 0.5mg/2ml
Salbutamol:
o Ventolin aerosol: 100g
o Resp. solution: 5mg/ml
o UDV / nebules: 2.5mg/2.5ml or 5mg/2.5ml
Hexoprenaline
o Discontinued Sulphate
Administration and Dosages

A. ACUTE BRONCHOSPASM

Aerosol
o
o

6 10 puffs should be administered during an episode

may then be repeated every 15 minutes, using a spacer

Inhalant solution: (use half the dosage for paediatrics)

o 2ml Fenoterol (1.25mg/2ml)(UDV) + 3ml N/S
o 2ml Fenoterol (0.5mg/2ml) (UDV) + 3ml N/S (paediatric solution)
o 1ml Fenoterol solution (1mg/ml) + 4ml N/S
o 1ml Salbutamol (5mg/ml) + 4ml N/S
o Repeat continuously if necessary

Unit Dose Vials

o UDV + N/S diluted up to 5ml

IPRATROPIUM BROMIDE

4.1

Ipratropium Bromide

Classification: Bronchodilators - anticholinergic

Schedule: 2
4.2

4.3

PharmaCOLOGY Action

Ipratropium bromide causes relaxation of bronchial muscles due to its anticholinergic effects
o (blocks parasympathetic system)
Its bronchodilation action is particularly effective in conjunction with 2-stimulants
Pharmaco-KINETICS

Onset of action : 30 minutes

Duration of action : 4-6 hours
4.4

Adverse Effects

With larger / repeated dosages

o it is absorbed from the lungs into the systemic circulation resulting in systemic anti-cholinergic
effects
Tachycardia
Dry, hot skin
Mydriasis
Urinary retention

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4.5

4.6

4.7

4.8

ILS PRACTITIONER PROTOCOLS

Indication

To be used in conjunction with 2-stimulants for acute bronchospasm

Contra Indication

Known hypersensitivity to ipratropium bromide or other anti-cholinergic drugs

Do not use in neonates
Precautions

The onset of action is only after 20 minutes, which is much longer than the 2-stimulants
o peak effectiveness at 60 90 minutes
The duration of action is 4 - 6 hours, which is also longer than the 2-stimulants
Packaging

Unit dose vial (UDV) containing

0.25 mg/2ml or 0.5 mg/2ml
Metered Dose Inhaler (300 doses) 40 g / inhalation (0.04mg)
Nebulizer solution (bottle)
0.25mg/ml

4.9
Administration and Dosages
Adults

UDV
o
o
o
o

Ipratropium bromide 0.5mg

+ appropriate 2 stimulant
+ balance of N/S to a
total of 5ml solution
Nebulised over 10 minutes

Aerosol
o The patient or ILS Provider may administer this during an episode.
o Two puffs of ipratropium bromide are administered if no improvement occurs following 2
stimulant administration Use of a spacer device is recommended.

Children > 5 years

UDV
o
o
o
o

Ipratropium bromide 0.5mg

+ appropriate 2 stimulant
+ balance of N/S to
total of 5ml solution
nebulised over 10 minutes

Children 1 to 5 years :

UDV
o
o
o
o

Ipratropium bromide 0.25mg

+ appropriate 2 stimulant
+ balance of N/S to a
total of 5ml solution
nebulised over 10 minutes

Children > 1 month to 1 year :

UDV
o
o
o
o

Ipratropium bromide 0.125mg

+ appropriate 2 stimulant
+ balance of N/S to a
total of 5ml solution
nebulised over 10 minutes
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4.10

ILS PRACTITIONER PROTOCOLS

NOTE

Ipratropium bromide + 2 stimulant have a synergistic effect

May be particularly useful in patients with bronchospasm who have taken beta-blockers
Typically given only once because of its prolonged onset of action; higher doses than those advocated
above, or dosing intervals less than four hours confer no added benefits.

DEXTROSE 50%

5.1

Dextrose (Carbohydrate)

Classification: Carbohydrate
Schedule: 1
5.2

5.3

5.4

5.5

5.6

5.7

PharmaCOLOGY Action

Glucose is a monosaccharide
o the most basic unit to which all carbohydrates are broken down
o and glucose is thus immediately available as a source of energy
Adverse Effects

Local irritation of vein

Thrombophlebitis
Local tissue necrosis
Hyperosmolarity
Diuresis
Hyperglycaemia
Indication

Acute management of symptomatic hypoglycaemia

Blood glucose < 3.5mmol/L and patient is clinically symptomatic
Decreased level of consciousness of unknown cause, with suspicion of associated hypoglycaemia / blood
glucose < 3.5mmol/L
Contra Indication

There are no absolute contra-indications in the presence of true symptomatic hypoglycaemia

Do not administer dextrose routinely during resuscitation unless there is confirmed hypoglycaemia
Precautions

Dehydration and hypovolaemia

o High concentrations of IV dextrose cause an increase in osmolality that draws H2O from the cells
and causes diuresis, aggravating dehydration
o Dehydration / hypovolaemia and hypoglycaemia must be corrected simultaneously
Intracranial haemorrhage
o Glucose leaking into the cerebral tissue will aggravate the injury and result in cerebral oedema
o Careful titration in all head injured patients is vital
Complications and adverse effects may be diminished by:

Limiting the use of dextrose to symptomatic hypoglycaemic patients

Administering dextrose slowly through a free-flowing IV line
Re-assessing the blood glucose 5 minutes post administration
Avoiding hyperglycaemia
Never combining dextrose and sodium bicarbonate in the same infusion (i.e. hyperosmolarity)

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5.8

Packaging

5.9

ILS PRACTITIONER PROTOCOLS

20ml & 50ml ampoules of a 50% solution (0.5g/ml)

50ml vacolitre containing a 50% solution
Administration and Dosages

Adults
10g (20ml of 50% solution) slowly IVI
Repeat every 5 minutes should blood glucose remain < 3.5mmol/l
Children (> 8years of age)
1ml/kg of a 50% solution which is then diluted to a 12.5% solution with sterile water
Repeat every 5 minutes should blood glucose remain < 3.5mmol/l
NOTE
If blood glucose remains < 3.5mmol/l after 3 doses, reassess patient, equipment and administration
technique
Treat the patient and not the test result

ORAL GLUCOSE POWER / GEL

6.1

Oral Glucose Powder / Gel

Classification: Carbohydrates
Schedule: 1
6.2

PharmaCOLOGY

Study of properties & effects of drugs

Pharmacology effects:
Therapeutic Effects
Side Effects

(desirable)
(undesirable / harmful)

Administration of oral glucose solution / preparation provides soluble (simple) carbohydrate to tissues in
order to raise Blood Glucose Levels.
6.3

Adverse Effects

Hyperglycaemia
6.4

Indication

Acute management of Hypoglycaemia

HGT <3.5mmol/l (HGT Haemoglocotest)
6.5

Contra Indication

No Absolute-contra indications
6.6

Precaution

Patient MUST be lateral if unconscious

Avoid aspiration
6.7

Packaging

Powder: 25g and 50g (per sachet)

Gel: 25g and 50g
6.8

Dosage and Administration

Gel: 25g gel applied to oral mucosa of pt. with gloved finger
Powder: dilute powder in glass of water (ONLY if pt. is conscious)
Repeat after 5min should blood glucose remain <3.5mmol/l
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ILS PRACTITIONER PROTOCOLS

MEDICAL OXYGEN

7.1

Medical Oxygen

Classification:
7.2

Natural Occurring Atmospheric Gas

PharmaCOLOGY

Study of properties & effects of drugs

Pharmacology effects:
Therapeutic Effects
Side Effects

(desirable)
(undesirable / harmful)

Colourless, tasteless, odourless gas

Present in atmosphere approx. 21% local atmospheric pressure
Reverses deleterious effects of hypoxeamia on the brain, heart and other vital organs
o (decrease amount of oxygen in tissue)
Expired air contains 16%-17% oxygen
During optimal active CPR only 25%-30% of normal cardiac output is maintained and for these
reason supplemental oxygen should be administered
o Good CPR with supplement O2 you can maintain normal cardiac output of 25-30%

7.3

Indication

GCS (Glasgow Coma Scale) <15/15 (below)

Any respiratory insufficiency or arrest
Acute de-compensation of COPD / Asthma
Chest pain (medical / trauma origin)
Cardiac arrest / cardiac failure
Toxic inhalations
SPO2 <90% (Oxygen saturation read with finger pulse oximetry)
ANY pt. with abnormal vital signs
Confirmed / suspected hypoxia (lack of O2 in blood)
Severe anaemia
Multiple/ severe trauma
Scuba diving accident (Nitrogen bubbles created in gaseous spaces in our bodies)
Prophylactically during are transport

7.4

Contra Indication

NO absolute contra-indication for use of oxygen in emergency setting

7.5

Precaution

Production of superoxide radicals in presence of paraquat (herbicide used to kills marijuana plants in
Mexico) paraquat and oxygen enhance each others toxicity causing severe pulmonary injury
High concentrations of oxygen may REDUCE respiratory drive of COPD pt. careful monitoring of pt.
required DO NOT without oxygen from these patients if condition is such the oxygen is required
Neonates with patent ductus arteriosus (PDA):
o should cyanosis and signs of hypoxia develop after oxygen administration remove oxygen
o Some infants with PDS and congenital heart disease the presence of PDA may be lifesaving
because of ductal-dependent systemic / pulmonary blood flow
Increased oxygen concentration tends to constrict foetal ductus arteriosus
Long exposure to high concentrations of oxygen may result in retrolental fibroplasia in neonates and
pulmonary fibrosis
Oxygen support combustion DO NOT use in presence of fire / smoke / cigarette smoking
High pressured oxygen should NOT be used with oil / grease based substances causes exothermic
reaction risk of explosion
REMOVE oxygen source to one metre away from defibrillation pads / paddles

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7.6

ILS PRACTITIONER PROTOCOLS

Packaging

Pressurised cylinder containing 100% medical oxygen

7.7

Dosage and Administration

Administered via:

Oxygen masks
Simple Mask
Venturi Mask
Partial Re-Breather Mask
Non-Re-Breather Mask
Nasal cannulae
Nebulizer device (5ml of saline)
Jet insufflation
Bag-Valve Mask/Tube (BVM)
Bag-Valve Mask/Tube Reservoir Device

Correct Flow rates (FiO2):

Nasal Cannulae
21-40% @ 1 6 L/min
Venturi Mask
24-50% @ 4 12 L/min
Simple Mask
35-60% @ 6 10 L/min
Partial Re-Breather Mask
35-70% @ 6 10 L/min
Non-Re-Breather Mask
60-100% @ 6 15 L/min
Bag-Valve-Mask/tube
50% @ 12 15 L/min
Bag-Valve-Mask/tube reservoir device
95-100% @ 15 L/min
(Adequate flow rate = Reservoir bag inflated > 1/3 at all time) Just under 1/3.

ENTONOX - NITROUS OXIDE AND OXYGEN

8.1

Entonox Nitrous Oxide and Oxygen

Classification:
Schedule:
8.2

Analgesic Gas
4

PharmaCOLOGY

Study of properties & effects of drugs

Pharmacology effects:
Therapeutic Effects
Side Effects

(desirable)
(undesirable / harmful)

Colourless, sweet-smelling, non-irritant gas

Heavier than room air / oxygen
Mild analgesic and anaesthetic effect depending on the dose inhaled
When inhaled it supressed the CNS (Central Nervous System) causing anaesthesia
High concentrations of oxygen delivered along with nitrous oxide INCREASES oxygen tension in the
blood thereby REDUCING hypoxia (Hypoxia lack of oxygen)
Provides rapid, easily reversible relief of mild to moderate pain relief

8.3

Pharmaco-KINETIC

HOW the body HANDLES the drug over period of time:

Absorption
o Absorption begins at site of administration
o RATE and EXTENT of absorption depends on:

Route of administration

Dosage
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ILS PRACTITIONER PROTOCOLS

Dosage form
Distribution
o distribution is transport of the drug through blood stream to various tissues at its action site
o Barriers to drug distribution: blood barriers / placental barrier

Biotransformation
o Process: drug is chemically converted to a metabolite (in order for body to metabolize drug)

Excretion
o Is elimination of toxic / inactive metabolites
o Kidneys primary organ for excretion
o Other organs: intestine / lungs / glands / skin
Above effects pt. response to drug therapy

EXTREMELY bloods-insoluble
NOT metabolised by the body
Eliminated by the lungs (small amounts eliminated through skin)
Onset action: 30-60 sec (MAX 3-4 min)
o Can last for up to 10 min

8.4

Adverse Effects

Light-headedness
Drowsiness
Nausea and Vomiting
8.5

Indication

Relief from pain from:

o Acute Myocardial Infarction
o Musculoskeletal trauma
o Burns NOT burn to respiratory tract
o Active labour
Any other condition requiring pain relief PROVIDED THERE ARE NO CONTRA - INDICATIONS

8.6

Contra Indication

GCS (Glasgow Coma Scale) <15/15 (below 15/15)

Neurological impairment:
o ANY altered level of consciousness
o Inability to comply with instructions
o Head injuries
Air Entrapment:
o COPD (Chronic Obstructive Pulmonary Disease)
o Asthma patient during an acute episode
o Acute Pulmonary oedema (Acute Sudden / Oedema Swelling)
o Chest Injuries
o Abdominal trauma
o Diving Accident SPECIFICALLY: Acute Decompression Illness
o Burns to the respiratory tract
Other limitations:
o SPO2 <90% mmHG (Oxygen saturation read with finger pulse oximetry)
o Major Facial Trauma

8.7

Precaution

Oxygen and nitrous oxide disassociate at <4C

IMPERITIVE that cylinder is inverted a few times and then placed horizontally when used in cold
conditions pt. will otherwise inhale pure nitrous oxide
Nitrogen has DECREASED solubility in blood

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ILS PRACTITIONER PROTOCOLS

Once in gas-containing space the gas dissociates and NITROGEN diffuses OUT SLOWER
than NITROUS OXIDE diffuses IN
o Causes a NET INCREASE in GAS VOLUME
When masked is removed after prolonged use
o gas will come out of solution in lungs and displace the oxygen in the alveoli causing
hypoxia
o Prevention: Mask must NOT be strapped to pt. face. Pt. must receive oxygen for 5-10min
Nitrous oxide is a NON-explosive gas

8.8

Packaging

Pressurised cylinders: mixture 52% nitrous oxide + 48% oxygen

(N2O+O2 52%: 48%)
8.9

Dosage and Administration

Entonox is predominantly a self-administered gas

Administration is to be explained carefully to pt. beforehand prevent unnecessary complications
Once pt. has inhaled enough Entonox to control the pain, they must remove the mask preventing chances
of overdosing
If pt. becomes drowsy REMOVE Entonox and replace immediately with oxygen
ONLY registered ALS may administer Entonox to pt.
As it require careful monitoring of pt. in order to prevent complications arising.

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ILS PRACTITIONER PROTOCOLS

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