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ADRENALINE

Last Updated 20 AUG 09

DRUG THERAPY PROTOCOL 1.003

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Any material that is printed is regarded as an uncontrolled copy

OFFICERS ARE ONLY TO PERFORM PROCEDURES FOR WHICH THEY HAVE RECEIVED SPECIFIC TRAINING AND AUTHORISATION BY THE QAS

Presentation

• 1mg in 1mL ampoule (1:1000)

Pharmacology

• Adrenaline is a naturally occurring catecholamine which primarily acts on Alpha (α) and Beta (β) adrenergic receptors, which are located mainly in tissues innervated by sympathetic nerves. The actions of these receptors

cause an increase heart rate (β1), increase the force of myocardial contraction (β1), increases the irritability of the

ventricles (β1), bronchodilation (β2) and peripheral vasoconstriction (α1) (1) Metabolism

• The majority of circulating adrenaline is metabolised by sympathetic nerve endings. It is subject to the process of mitochondrial enzymatic breakdown by mono-amine oxidase (MAO) at synaptic level (2)

Indications

• Anaphylaxis

• Asthma or severe bronchospasm with imminent arrest cardiac arrest

• Bradycardia with poor perfusion unresponsive to Atropine and / or pacing

• Cardiac arrest

• Cardiogenic shock

• Croup with life threatening airway compromise

• Shock (excluding haemorrhagic causes) that is unresponsive to adequate fluid resuscitation Contra-Indications

• Known severe adverse reaction

Precautions

• Patients taking monoamine oxidase inhibitors (MAOIs) (2)

• Hypovolaemic shock

• Hypertension Side Effects

• Anxiety

• Hypertension

• Palpitations

• Tachyarrhythmia’s

• Pupillary dilation Routes of Administration

• Intramuscular- anterolateral aspect of deltoid or quadricep

• Intravenous

• Nebulised

• Endotracheal

• Intraosseous Drug Effect

Onset 30 – 90 seconds Intramuscular Peak 4 – 10 minutes Duration 5 – 10 minutes

Onset 30 seconds Intravenous Peak 2 minutes Duration 5 – 10 minutes

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DOSE

P1 - Paramedic Not authorised for use

P2 - Advanced Skills Paramedic Not authorised for use

P3 - Advanced Care Paramedic ADULT Anaphylaxis I.M.I. 250 - 500mcg (0.25 - 0.5mg) May be repeated at 5 minute intervals only whilst patient continues to have life-threatening presentation No maximum dose Asthma or severe bronchospasm with imminent arrest (altered consciousness or haemodynamic compromise) I.M.I. 250 – 500mcg (0.25 - 0.5mg) May be repeated at 5 minute intervals only whilst patient continues to have a life-threatening presentation No maximum dose Cardiac arrest I.V.I. 1mg as a bolus To be repeated by 1mg every 3-5 minutes if required No adult doses to be diluted DILUTION FOR CHILD ADRENALINE DOSES (IV) for P3 1mg (1mL) of Adrenaline to be drawn up in a 10ml syringe with 9mL Normal Saline (1:10,000) This gives 1ml solution = 100mcg CHILD Anaphylaxis I.M.I. 10mcg / kg. Single dose not to exceed 250mcg (0.25mg) May be repeated at 5 minute intervals whilst patient has a life threatening presentation No maximum dose Asthma or severe bronchospasm with imminent arrest (altered consciousness or haemodynamic compromise) I.M.I. 10mcg / kg. Single dose not to exceed 250mcg (0.25mg) May be repeated at 5 minute intervals whilst patient has a life threatening presentation No maximum dose Cardiac arrest I.V.I. If child <10kgs (1 year) then 100mcg as a bolus If child >10kgs (1 year) then 10mcg/kg To be repeated every 3-5 minutes if required Croup (with life threatening airway compromise) Nebulised 2mg Single dose only

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DOSE

CHILD Cardiac arrest I.V.I. / I.O. If child <10kgs (1 year) 100mcg as a bolus.

If child >10kgs (1 year) then 10mcg / kg To be repeated every 3-5 minutes if required E.T.T. route all doses 100mcg/kg Anaphylaxis I.M.I. 5 - 10mcg / kg. Single dose not to exceed 500mcg (0.5mg) May be repeated at 5 minute intervals I.V.I. / I.O. 1 - 2mcg / kg. Single dose not to exceed 50mcg (0.05mg) May be repeated at 2 minute intervals E.T.T. Double the I.V.I. dose Asthma or severe bronchospasm with imminent arrest (Altered consciousness or haemodynamic compromise) I.M.I. 5 - 10mcg / kg. Single dose not to exceed 500mcg (0.5mg) May be repeated at 5 minute intervals I.V.I. / I.O. 1 - 2mcg / kg. Single dose not to exceed 50mcg (0.05mg) May be repeated at 2 minute intervals E.T.T. Double the I.V.I. dose Croup (with life threatening airway compromise) Nebulised 2mg Single dose only

P4 - Intensive Care Paramedic

DOSE DILUTIONS FOR P4 1mg adrenaline to be drawn up with 9mL Normal Saline in a 10mL syringe (1:10,000) This gives 1mL solution = 100mcg To double dilute, draw off 1mL of above solution (100mcg) and add 9mL Normal Saline in a 10mL syringe (1:100,000) This gives 1mL solution = 10mcg ENSURE ALL DOSES and SYRINGES LABELLED APPROPRIATELY ADULT Anaphylaxis I.M.I. 250 - 500mcg (0.25 – 0.5mg) May be repeated at 5 minute intervals until perfusion and respiratory status normalises No maximum dose I.V.I. 20 - 50mcg (0.02 – 0.05mg) May be repeated every 60 seconds until perfusion and respiratory status normalises No maximum dose E.T.T. Double the I.V.I dose Asthma or severe bronchospasm with imminent arrest (altered consciousness or haemodynamic compromise) I.M.I. 250 – 500mcg (0.25 -0.5mg) May be repeated at 5 minute intervals until perfusion and respiratory status normalises No maximum dose I.V.I. 20 - 50mcg (0.02 – 0.05mg) May be repeated every 60 seconds until perfusion and respiratory status normalises No maximum dose E.T.T. Double the I.V.I. dose Bradycardia with poor perfusion that is unresponsive to Atropine / pacing I.V.I. 20 - 50mcg (0.02 – 0.05mg) May be repeated every 60 seconds until perfusion improves No maximum dose E.T.T. Double the I.V.I. dose Cardiac arrest I.V.I. 1mg as a bolus To be repeated by 1mg every 3-5 minutes if required E.T.T. Double the I.V.I dose Cardiogenic shock I.V.I. 20 -50mcg (0.02 - 0.05mg) May be repeated every 60 seconds until perfusion improves No maximum dose E.T.T. Double the I.V.I. dose

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DOSE

P4 - Intensive Care Paramedic CHILD Anaphylaxis I.M.I. 10 mcg/kg. Single dose not to exceed 250mcg (0.25mg) May be repeated at 5 minute intervals No maximum dose I.V.I. / I.O. 2 mcg/kg. Single dose not to exceed 50mcg (0.05mg) May be repeated at 2 minute intervals No maximum dose E.T.T. Double the I.V.I. dose Asthma or severe bronchospasm with imminent arrest (altered consciousness or haemodynamic compromise) I.M.I. 10 mcg/kg. Single dose not to exceed 250mcg (0.25mg) May be repeated at 5 minute intervals No maximum dose I.V.I. / I.O. 2 mcg/kg. Single dose not to exceed 50mcg (0.05mg) May be repeated at 2 minute intervals No maximum dose E.T.T. Double the I.V.I. dose

Cardiac arrest I.V.I. / I.O. If child <10kgs (1 year) 100mcg as a bolus

If child >10kgs (1 year) then 10 mcg/kg To be repeated every 3-5 minutes if required E.T.T. route all doses 100 mcg/kg Not to exceed the adult dose Croup (with life threatening airway compromise) Nebulised 2mg

TRIAL - AGL Action Rescue (Maroochydore base only) Intensive Care Paramedic Extended Scope of Role (ESoR) - Aeromedical (QCC CONSULT APPROVAL REQUIRED IN ALL SITUATIONS) ADULT Shock (excluding haemorrhagic causes) that is unresponsive to adequate fluid resuscitation. Mix 3mg (3mL) of Adrenaline with 47mL of Normal Saline 0.9% or Glucose 5% in a 50mL syringe to achieve a final concentration of 60mcg/mL. Ensure all syringes are appropriately labelled. Commence infusion at 2 mcg/min (2 mL/hr) and increased by 1-2 mcg/min (1-2 mL/hr) every 3-5 minutes until patient’s blood pressure returns to an appropriate level.

Rate (mL/hr)

Concentration – 3mg/50mL (mcg/min)

1 1 mcg/min

2 2 mcg/min

3 3 mcg/min

CHILD Not approved Special notes:

• Full cardiac monitoring is required for all patients on Adrenaline infusions.

• Vasopressor and inotropic agents should be administered through a central venous line where possible.

• Invasive pressure monitoring (ART) should be used for all patients receiving intravenous inotrope infusions.

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SUPPORTING EVIDENCE

Reference (1):

• Australian Resuscitation Council 2006 ‘Medication in adult advanced life support’ Guideline 11.6

• Te OH 1997 ‘Intensive Care Manual’ 4th ed

Reference (2):

• ‘When an adrenergic nerve is stimulated, the action potential travels along the axon until it reaches the nerve terminal. Depolarisation of the terminal causes the release of chemical transmitter noradrenaline (NA) into the synaptic gap. NA diffuses across the gap and interacts with adrenergic postsynaptic receptors, triggering an effector response’

• ‘The transmitter is removed from the synapse by an amine re-uptake pump and is restored to the synaptic vesicles. Any excess transmitter within the terminal not restored to the vesicles is degraded by the mitochondrial enzyme mono-amine oxidase (MAO)’

• ‘Mono-amine oxidase inhibitors (MAOIs) are a group of anti-depressant drugs that act to raise the synaptic levels of endogenous amines by preventing the degradation of excess transmitter (NA) after its release’

• Galbraith et al 2001 ‘Fundamentals of pharmacology’ 3rd

ed

Further reading:

• Angelos et al 2007 ‘Cardiovascular response to epinephrine varies with increasing duration of cardiac arrest’ J of Resuscitation Vol 77

• Australian Resuscitation Council 2006 Pharmacology Guidelines

• ‘There is no evidence that giving any anti-arrhythmic drug routinely during human cardiac arrest increases rate of survival to discharge. Despite the lack of human long-term outcome data, it is reasonable to continue to use anti- arrhythmic drugs on a routine basis’. Consensus on Science and Treatment Recommendations Part 4: Advanced Life Support Resuscitation 2005 Vol 67 No 2-2

• Hollenberg et al 2008 ‘Improved survival after out-of-hospital cardiac arrest is associated with an increase in proportion of emergency crew-witnessed cases and bystander cardiopulmonary resuscitation’ J of Resuscitation Science Vol 118 No 4

• Nolan et al 2002 ‘Advanced life support drugs: do they really work? J of Cardiopulmonary Resuscitation Vol 8 No 3

• Woodhouse et al 1995 ‘High dose and standard dose adrenaline do not alter survival, compared with placebo in cardiac arrest’ J of Resuscitation Vol 30

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