Doctor's emergency bag

This page of GPnotebook is derived from suggestions for the contents of the doctor's bag made in Drug and Therapeutics Bulletin reviews (1,2):

Analgesia

Suggested analgesics to include in the doctor's bag include:

• diamorphine - this is an effective treatment for adults in severe pain (5mg or 10mg in ampoules for reconstitution with water for injection)
  • in an adult, administered as 1.25-5mg by slow i.v. injection, especially if the patient is shocked or has peripheral vasoconstriction, or 5-10mg subcutaneously or intramuscularly
  • an alternative to diamorphine is morphine (10mg/mL injection; 10mg/5mL oral solution), which can be given subcutaneously (but not if the patient is oedematous) or intramuscularly in a dose of 10mg (15mg for heavier well-muscled patients); by slow (2mg/minute) intravenous injection in a dose of 2.5-7.5mg; or orally in a dose of 5-20mg
  • the controlled drug status of diamorphine and morphine (not oral solutions <13mg/5mL) means, of course, that they must be kept locked in a bag or container and stored in a secure and locked space (i.e. car boot or cupboard), and their use must be recorded in a controlled drugs register
• diclofenac (25mg/ml injection) - administered to adults intramuscularly deep into gluteal muscle; useful for bone pain, ureteric colic, acute back and other musculoskeletal pain. The dose may be repeated after 30 minutes with the second dose administered into the other buttock. An alternative route for diclofenac administration is via suppositories. The maximum adult dose of diclofenac via any route is 150 mg
• paracetamol (500mg tablets and 120mg/5ml paediatric oral solution or suspension)
• ibuprofen (100mg/5ml suspension) - this is also useful for reducing fever in young children

.Opioid overdose

• naloxone (400mcg/ml injection) - this should be included in the doctor's bag of any GP who may administer diamorphine. If there is an acute opioid overdose (i.e. if there is coma, bradypnoea and pinpoint pupils) in an adult then 0.8-2mg should be given. In most cases, the first dose of naloxone should be administered intramuscularly because this avoids rapid, and possibly aggressive arousal, that follows i.v. administration
  • naloxone has a shorter duration of action than many opioids and close monitoring and repeated injections may be necessary, according to the respiratory rate and depth of coma (dose can be repeated every 2-3 minutes up to a maximum of 10mg)
    • if there is still no response after the maximum dose has been given, the diagnosis of opioid overdose should be questioned - note though that the doses of naloxone mentioned may be too low for managing overdose in people who have been taking opioids long term
    • any patient who has had an opioid overdose must be admitted to hospital - this is because repeated naloxone doses, or an infusion may be required

Asthma

If acute asthma:

• initial treatment is beta2-agonist administered via a large volume spacer or nebuliser e.g. salbutamol (1mg/1ml nebuliser solution) 2.5-5mg
• corticosteroid therapy may be indicated in acute asthma. Either prednisolone if patient can swallow or, in acute severe asthma, an i.v.bolus of hydrocortisone (in adults, 100mg powder as sodium succinate for reconstitution) given over at least 60 seconds
• high-flow oxygen should be given whenever possible
• refer to linked management of acute asthma

Infection

• benzylpenicillin (600mg vial for reconstitution with sodium chloride or water for injection) for use in cases of suspected bacterial meningitis
  • if patient is allergic to penicillin then the patient should, in general, receive cefotaxime
  • it is too dangerous to risk using cefotaxime in patients with a history of anaphylaxis due to penicillin; a non-beta-lactam alternative for such individuals is intravenous chloramphenicol (2)
• for uncomplicated pneumonia: amoxicillin or erythromycin if penicillin allergic
  • patients who are fit to be managed at home can be treated with oral antibacterials; patients needing intravenous antibacterials should be admitted to hospital.
• for urinary tract infections: trimethoprim
• for cellulitis or acute skin infections: flucloxacillin plus amoxicillin
• oral cephalosporin may also be carried for use as a second-line drug for urinary tract infections for older people in nursing homes and for severe urinary infections
• aciclovir (800mg tablets), 800mg five times daily for 7 days, is useful for the immediate treatment of herpes zoster in an adult

Nausea and Vomiting

• in adults with vestibular disorders cyclizine (50mg/5ml), either administered intramuscularly or i.v., can be used; alternatives include prochlorperazine and metoclopramide. Because of the risk of oculogyric crisis the use of metoclopramide in patients under 20 years of age should be restricted to treatment of severe intractable vomiting of known cause (1)
• cyclizine
  • can also be given to reduce the likelihood of opioid-induced vomiting
  • however cyclizine is not recommended if a patient has suffered a myocardial infarct because it causes peripheral vasonstriction (counteracting the haemodynamic effect of opioids). In this situation a better choice is metoclopramide
• domperidone (10mg tablets; 30mg suppositories) 10-20mg by mouth, or 60mg rectally, is a useful antiemetic especially for nausea and vomiting associated with cytotoxic therapy
  • has the advantage over metoclopramide and prochlorperazine of being less likely to cause dystonia
  • also used to treat women with vomiting due to emergency hormonal contraception
• metoclopramide and prochlorperazine are alternative antiemetics
  • can cause acute dystonia including oculogyric crisis, particularly in young and elderly people. This effect can be reversed by procyclidine (5mg/mL injection). A dose of 5-10mg (occasionally more than 10mg), given intramuscularly or intravenously, is usually effective in 5-10 minutes but may take up to 30 minutes to provide relief

Pyschiatric emergencies

• if acutely anxious, agitated or psychotic adult, establishing a good rapport and attempting to calm them down are more appropriate emergency measures than giving medication
  • if there are any concerns about personal safety, the GP should not attend the patient alone
  • if medication for reducing anxiety or agitation is considered necessary, it should be given by mouth wherever possible, rather than by injection
    • if parenteral treatment (i.e. for rapid tranquillisation) is necessary, the intramuscular route is safer than the intravenous route
    • oral treatment options include:
      • haloperidol (1.5mg tablets) 1.5-5mg, or,
      • lorazepam (1mg tablets) 1-2mg
      • doses depend on the weight of the patient and the degree of psychiatric disturbance
  • a patient who is very agitated, hyperactive or violent can be given 2-10mg of haloperidol (5mg/mL injection) intramuscularly or 1-2mg of lorazepam (4mg/mL injection) intramuscularly
    • haloperidol, chlorpromazine, metoclopramide and prochlorperazine can cause oculogyric crisis or acute dystonia (especially in young and very old people) and this can be reversed by procyclidine (5mg/5ml) 5-10mg dose in an adult given intramuscularly, and repeated after 20 minutes if symptoms persist
  • for a patient with acute agitation due to organic disease, treatment with lorazepam 1-2mg orally is reasonable
    • dose depends on the patient's size and degree of agitation
    • if the patient is too agitated to take drugs by mouth, then parenteral lorazepam should be given.
    • if respiratory depression occurs (though unlikely with the intramuscular doses recommended), it can be quickly reversed by giving flumazenil
    • flumazenil is contraindicated in patients with life-threatening conditions that are controlled by benzodiazepines (e.g. raised intracranial pressure or status epilepticus)
    • patients with benzodiazepine-induced respiratory depression should be admitted to hospital.

Bleeding

• sodium chloride infusion (0.9%, 500mL) with a giving set and intravenous cannula - this facilitates fluid volume replacement in patients with severe bleeding
• if severe bleeding after a delivery or incomplete miscarriage
  • syntometrine given intramuscularly (intravenous use no longer recommended), will often stop the bleeding after a delivery or an incomplete miscarriage

Dehydration

• oral rehydration salts

Diabetic emergencies

• glucose for hypoglycaemia - available as an oral gel in a dispenser (Hypostop)
• glucagon (1mg/ml injection) is useful if glucose ineffective or impossible to administer
  • if an adult patient does not respond to glucagon after 10 minutes, or those who have been hypoglycaemic for some time and may have exhausted their supplies of liver glycogen, up to 50mL of intravenous glucose solution (20% intravenous infusion) should be given into a large vein through a large-gauge needle
  • if the hypoglycaemia has been caused by an oral antidiabetic drug or an insulin overdose, the patient should be transferred to hospital (2)

Anaphylaxis

• airway should be secured and to help restore blood pressure, the patient should be laid supine with the feet raised above the level of the head
• epinephrine (adrenaline) (1mg/mL ampoules, i.e. 1:1000)
  • should be given intramuscularly or subcutaneously for anaphylaxis or acute angio-oedema with threatened airway obstruction
• chlorphenamine (chlorpheniramine) (10mg/mL injection)

Seizures:

• drug of choice for the initial management of status epilepticus in adults is lorazepam (4mg/mL injection) 4mg by slow intravenous injection into a large vein
• rectal diazepam is an alternative for prolonged or serial seizures and for status epilepticus in adults
• midazolam given by the buccal route (e.g. via a syringe) may be more acceptable to some patients, although it is not licensed for this indication

Myocardial infarction:

• aspirin (300mg soluble tablets)
• diamorphine for analgesia
  • diiamorphine should not be injected intramuscularly in patients with myocardial infarction because this may delay the analgesic effect and be ineffective in a patient with shock. It may also increase the risk of local bleeding into the muscle if the patient is subsequently given a thrombolytic drug
• atropine (600mcg/mL), 300mcg i.v. increasing to 1mg as necessary, should be administered if the patient has bradycardia (pulse rate < 50 beats per minute) plus hypotension (systolic blood pressure < 90 mmHg)
• glyceryl nitrate spray
• oxygen, if carried, should also be given at the highest deliverable concentration (provided that the patient does not have chronic obstructive pulmonary disease)
• some GPs may wish to administer thrombolytic therapy in patients with clinical and ECG evidence of acute myocardial infarction to ensure that this treatment is given as soon as possible (2) - the thrombolytic regimen should be decided in conjunction with the local specialist cardiologists

Left heart failure

• furosemide (frusemide) (10mg/mL injection) 20-50mg should be given
• diamorphine (5mg powder for reconstitution with water for injection) should be given (with an antiemetic) by slow intravenous injection (1mg/minute) in a dose of 2.5-5mg for symptomatic relief in acute left ventricular failure
• glyceryl trinitrate can help to relieve pulmonary oedema in acute left ventricular failure
• oxygen, if carried, should also be given at the highest deliverable concentration (unless the patient has chronic obstructive pulmonary disease)

To relieve pulmonary oedema, furosemide* (10mg/mL injection) 20-50mg should be given by slow intravenous injection.

Hypoadrenalism

• acute hypoadrenalism (resulting in shock and hypotension) is likely to require hospital admission for i.v. fluids and regular parenteral hydrocortisone. In an adult, hydrocortisone 100mg by slow i.v. or intramuscular injection provides adequate circulating corticosteroid levels for any severe stress only for a period of 4-6 hours
• patients who have had a hypoadrenal crisis requiring parenteral therapy should be admitted to hospital in all but the mildest cases

Please note that summary of product characteristics must be consulted before prescribing any drug mentioned in this section of GPnotebook.

Reference:

1. Drug and Therapeutics Bulletin 2000; 38 (9): 65-68
2. Drug and Therapeutics Bulletin 2005;43(9): 65-68.