Welcome to the example

Emergency Drugs File

• The contents of this file represent a local project still under development.
• Your local protocols and stocked drug preparations/concentrations may well
be different.
• Feel free to replicate the format if you like it (it can be supplied in Pages for
Mac if you wish to amend for local use) but it is supplied as a working draft
and it is of course your responsibility to check and ensure all material is correct
before use in your organisation.

This Emergency Drugs File started life in a tiny GP-led Ambulatory Care Unit in a small
community hospital. The ACU only accepts low-acuity patients - there is no Emergency
Department, CCU or ITU on site, and limited diagnostics - but occasionally patients either
slipped through the net, or turned up at the adjacent Minor Injury Unit, with serious medical
conditions requiring immediate treatment whilst awaiting urgent ambulance transfer to an ED.

This Emergency Drugs File was designed to cognitively offload the doctor and nurse on duty,
reducing the stress and improving the effectiveness of treating immediately life-threatening
emergencies in a low-acuity unit, where staff may be unaccustomed to treating these
emergencies (or unaccustomed to treating these emergencies outside of an ED setting!).

I am making it available as it may be a helpful concept to adopt to support redeployed staff

working in unfamiliar settings during the COVID19 pandemic.

Each section consists of:

• Prescribing aide memoire (bringing together dose and administration instructions for
essential drugs - including reminders of what other drugs may be required),
• Where to find the relevant drugs in our tiny community hospital,
• A crib-sheet how to prepare and give the drug in the simplest possible way (scrolling
frantically through Medusa, trying to work out the easiest way to prepare and administer an
unfamiliar drug, is not a pleasant experience, especially when multiple different options are
presented).
• Relevant protocols (national where possible, local if not).

CONTENTS

1. Hyperkalaemia 5. Anaphylaxis
2. Severe Sepsis antibiotics (first doses) 6. SVT
3. Bradycardia 7. Magnesium
4. Status Epilepticus

Dr Linda Dykes FRCEM

Consultant in Emergency Medicine & GPwER Ambulatory Care
[email protected] - @DrLindaDykes on Twitter
 


Calcium Gluconate 10%

Indication:

Hyperkalaemia (high potassium)

‣ K+ above 6.5 ‣ Peaked T-waves ‣ Absent or
‣ Broad QRS flattened P waves
or Complex ‣ Sine wave
‣ ECG changes ‣ Bradycardia ‣ VT

Dose Where to find it

‣ 30ml of calcium gluconate ‣ LLGH Emergency Drug

injection 10% Cupboard

How to administer the drug How to prepare the drug

‣ No dilution required
‣ Slow IV injection over 5-10 mins,
preferably into a large Other drugs you will need
peripheral vein.
Monitoring required ‣ Salbutamol nebulisers
‣

‣ Glucose* & insulin

‣ ECG monitor infusion (125ml of Glucose
‣ Perform 12-lead ECG post-dose 20%/ 250ml of Glucose
‣ Fingerprick glucose at 15, 30, 10% mixed with soluble
and 60 minutes (up to 1:10 insulin (Actrapid) 10 units)
patients will develop
hypoglyaemia) then every 30 *ACU does not stock Glucose 50%

minutes

ACU Emergency Drugs File Working Draft v1.0 April 2020

 Glucose/insulin infusion



Indication:

Hyperkalaemia (high potassium)

‣ K+ above 6.5 ‣ Peaked T-waves ‣ Absent or
‣ Broad QRS flattened P waves
or Complex ‣ Sine wave
‣ ECG changes ‣ Bradycardia ‣ VT

Dose Where to find it

‣ Glucose 25g + soluble insulin
(Actrapid) 10 units over 15 ‣ Glucose 20%: ACU stock
minutes ‣ Soluble insulin (Actrapid):
ACU stock
How to administer the drug
How to prepare the drug
‣ 125ml of Glucose 20%
plus ‣ Add Actrapid 40 units to
‣ Actrapid 10 units 500ml of Glucose 20%
(i.e. make up a quadruple
Monitoring required
quantity) and give 125ml
‣ ECG monitor of this mixture over 15
‣ Perform 12-lead ECG post-dose mins via infusion pump
‣ Fingerprick glucose at 15, 30, ‣ Take care to ensure the
and 60 minutes (up to 1:10 Actrapid is not injected
patients will develop into the dead space of the
hypoglyaemia) then every 30 injection port of the
minutes glucose bag.

Other drugs you will need

‣ Salbutamol nebulisers
‣

‣ Calcium Gluconate 10%

ACU Emergency Drugs File Working Draft v1.0 April 2020

Salbutamol nebs



Indication:

Hyperkalaemia (high potassium)

‣ K+ above 6.5 or ECG changes ‣ Peaked T-waves
‣ Broad QRS Complex
‣ Bradycardia
‣ Absent or flattened P waves
‣ Sine wave
‣ VT

Dose Where to find it

‣ Salbutamol 10-20mg nebuliser ‣ ACU drug cupboard

How to administer the drug How to prepare the drug

‣ Avoid if tachyarrythmias ‣ Via standard nebuliser,

‣ Use 10mg if history IHD ideally air-driven if patient
‣ Use 20mg if on a beta-blocker is not hypoxic (but priority
is delivering the drug)
Monitoring required
Other drugs you will need
‣ ECG monitor
‣ Perform 12-lead ECG post-dose
‣ Glucose/insulin infusion
‣ Fingerprick glucose at 15, 30, ‣

‣ Calcium Gluconate 10%

and 60 minutes (up to 1:10
patients will develop
hypoglyaemia) then every 30
minutes

ACU Emergency Drugs File Working Draft v1.0 April 2020

Hyperkalaemia (high potassium)
NAME:

Emergency Management of ADDRESS:

D.O.B.:
Hyperkalaemia in Adults CHI:

Hyperkalaemia (K+ ≥ 5.5 mmol/L)

Consider initiating treatment if Hyperkalaemia suspected and K + unknown Date: ___/___/___ Time: ___:___

Assess Airway Breathing Circulation Disability Exposure (ABCDE) Approach

First 15-30 min
Patient Seek expert help if airway, breathing or circulation compromised

Perform 12-lead ECG

Na+: ______ 02 Sat: _____%
+
K: ____.__ RR: ______
Urea: ____.__ BP: ____/___
MILD MODERATE SEVERE
+ + + Creat: ______ Pulse: ______
K 5.5 - 5.9 mmol/L K 6.0 - 6.4 mmol/L K ≥ 6.5 mmol/L
Time: ___:___ EWS: ______
Consider cause and if Treatment guided by clinical Emergency treatment
treatment indicated scenario, ECG and rate of rise indicated
+
Check K
Seek expert help! Send lithium-heparin sample to lab
Use blood gas analyser if available
Exclude pseudo-hyperkalaemia
Monitor ECG in high dependency area
Sick patient; K+ ≥ 6.5 mmol/L; Acute ECG changes present
Dialysis patient: Contact Renal Unit
Cardiac monitoring: YES/ NO
Acute ECG changes present (tick if present)?
NO □ Peaked T waves □ Absent or flattened P waves Call for senior help: YES/ NO
□ Broad QRS □ Sine wave Renal or ICU referral: YES/ NO
□ Bradycardia □ VT
IV Calcium (6.8 mmol)
YES 10 ml 10% Calcium Chloride IV OR
30 ml 10% Calcium Gluconate IV
Protect the Calcium Chloride OR Calcium Gluconate IV Use large vein
Heart Give over 5-10 min
Repeat ECG and consider further dose after 5 min if ECG changes persists

Next 30-60 min

Insulin–Glucose IV Infusion
Give in severe hyperkalaemia
Consider in moderate hyperkalaemia (assess ECG and rate of rise) Glucose (25 g) over 15 min
+
Shift K 50 ml 50% Glucose OR
into cells 125 ml 20% Glucose,
(See glucose preparations) WITH Soluble Insulin – 10 units
Salbutamol 10-20 mg Nebulised
Give in severe hyperkalaemia Salbutamol
Consider in moderate hyperkalaemia (assess ECG and rate of rise) Give 10 mg if history of IHD
Avoid if tachyarrhythmia present
Blood Monitoring:
Remove K
+ Consider Consider Dialysis Baseline Glucose __.__ K+ ___.__
from body Calcium Resonium 15 min Glucose __.__
Seek advice from Renal or ICU team; 30 min Glucose __.__
15 g x4/day oral or 30 g x2/day PR patient transfer may be required
60 min Glucose __.__ K+ ___.__
K ≥ 6.5 mmol/L despite
medical therapy

Monitor K+ Monitor serum K+ and blood glucose After 1st hour

and Blood
Glucose
Blood Monitoring:
Consider cause of hyperkalaemia, prevent further rise and recurrence 90 min Glucose __.__
Prevention 120 min Glucose __.__ K+ ___.__
Stop all nephrotoxic medication including ace-inhibitors, angiotensin II receptor
blockers, potassium-sparing diuretics, NSAIDS and assess diet 180 min Glucose __.__
240 min Glucose __.__ K+ ___.__
360 min Glucose __.__ K+ ___.__
K+: potassium; Na+: sodium; Creat: creatinine; IV: intravenous; min: minutes; PR: per rectum; EWS:
early warning score; IHD: Ischaemic Heart Disease; NSAIDS: non-steroidal anti-inflammatory drugs 24 hours K+ ___.__

Publication date: 1.03.14 Review date: 1.03.16

Renal Association 2014 - their stated revision date was 2019, but still current in Feb 2020.
Adenosine



Indication:

Supraventricular tachycardia (SVT)

‣ Try vagal manoeuvres using the Modified Valsalva Manouevre before
reaching for the adenosine (43% success rate in the REVERT trial)
‣ If unstable/Adverse features present and DC cardioversion is required, start
at 70-120J in narrow-complex tachycardias

Dose Where to find it

‣ 6mg rapid IV bolus (2 seconds) ‣ LLGH MIU or Theatre

‣ If no effect, give 12mg after 1-2
minutes How to prepare the drug
‣ If no effect, give a further dose
of 12mg after 1-2 minutes ‣ Comes as 6mg/2ml vials
‣ Use smallest possible
How to administer the drug syringe
‣ Does not require dilution
‣ By rapid IV bolus, followed
‣ Have the saline flush ready
immediately by 20ml N/S flush
‣ Use a large peripheral vein What to expect
Monitoring required ‣ Warn patients that they can
feel very peculiar during the
‣ Move to MIU resus room
adenosine bolus!
‣ Full monitoring (including ECG)
‣ There may be a short period of
‣ Record ECG continuously whilst
asystole on the monitor, this is
giving the adenosine boluses
completely normal (NB -
Other drugs you will need patients say it feels horrible)
Adenosine is contraindicated in
‣ None available in community
asthma, bronchoconstrictive/
hospital setting. Calcium channel bronchospatstic lung disease, atrial
blockers are an alternative. fibrillation, and WPW.

ACU Emergency Drugs File Working Draft v1.0 April 2020

Supraventricular tachycardia (SVT):



Modified Valsalva Manoeuvre

Using this sequence improves the success rate for the Valsalva manoeuvre from 17% to 43%
(defined as the patient being back in sinus rhythm at one minute) in the REVERT trial

You will need:

‣ MIU trolley with quickly adjustable backrest
‣ 20ml syringe
‣ At least three helpers
‣ ECG monitoring

15 seconds of blowing into the

1 end of a 20-ml syringe whilst
sitting semi-recumbent
(“try to blow the plunger out”)

then QUICKLY switch position to:

15 seconds with legs lifted at

2 45 degrees whilst patient lies
supine

Helper 1 - drops back rest

Helpers 2 & 3 - lift one leg each

‣ After the manoeuvre patient

3 can return to semi-recumbent.
‣ Watch the monitor: success in
the trial was measured 30
seconds after the end of the
legs-up phase.

Diagrams courtesy of
ACU Emergency Drugs File Working Draft v1.0 April 2020 ECGmedicaltraining.com
 Adult Tachycardia (with pulse) Algorithm
Assess using the ABCDE approach
Monitor SpO 2 and give oxygen if hypoxic
Monitor ECG and BP, and record 12-lead ECG
Obtain IV access
Identify and treat reversible causes (e.g. electrolyte abnormalities)

Yes - Unstable Adverse features?

Synchronised DC Shock* Shock
Up to 3 attempts Myocardial ischaemia
Syncope Heart failure

Seek expert help No - Stable

! Is QRS narrow (< 0.12 s)?
Amiodarone 300 mg IV over 10-20 min
Repeat shock
Then give amiodarone 900 mg over 24 h
Broad Narrow

Broad QRS Narrow QRS

Is QRS regular? Is rhythm regular?
Regular Irregular

Resuscitation Council Guidelines 2015 - due for update in 2020

Vagal manoeuvres Probable AF:
Irregular Regular Adenosine 6 mg rapid IV bolus Control rate with beta-blocker or
if no effect give 12 mg diltiazem
if no effect give further 12 mg If in heart failure consider digoxin or
Monitor/record ECG continuously amiodarone
Assess thromboembolic risk and
consider anticoagulation
Seek expert help Sinus rhythm achieved?
! If VT (or uncertain rhythm):
Amiodarone 300 mg IV over 20- Yes No
60 min then 900 mg over 24 h
Possibilities include:
AF with bundle branch block If known to be SVT with bundle Seek expert help
treat as for narrow complex Probable re-entry paroxysmal SVT: !
Supraventricular tachycardia (SVT)

branch block:
Pre-excited AF Record 12-lead ECG in sinus rhythm
Treat as for regular narrow-
consider amiodarone If SVT recurs treat again and consider Possible atrial flutter:
complex tachycardia
anti-arrhythmic prophylaxis Control rate (e.g. with beta-blocker)
*Conscious patients require sedation or general anaesthesia for cardioversion
Atropine



Indication:

Bradycardia (with adverse features)

‣ Shock ‣ Myocardial ischaemia
‣ Syncope ‣ Heart Failure

Dose Where to find it

‣ 300-500* micrograms IV ‣ LLGH Emergency Drug

‣ Repeat if necessary to a Cupboard
maximum of 3mg
*500 micrograms is the dose in the ALS
Bradycardia algorithm
How to prepare the drug

How to administer the drug ‣ If patient is very unwell, for

the first dose, you can use
By IV bolus injection
the 600 microgram/ml vial
as it is
Monitoring required
‣ Follow with 20 ml N/S flush
‣ If less urgent, dilute the
‣ Move to MIU resus room
atropine 600 microgram/
‣ Full monitoring (including ECG)
ml vial with 5ml of N/Saline
‣ Obs q10-15 min
to produce a 100
Other drugs you will need micrograms/ml solution.

‣ Adrenaline in case of cardiac

arrest

ACU Emergency Drugs File Working Draft v1.0 April 2020

Bradycardia (with adverse features)
Adult Bradycardia Algorithm

Assess using the ABCDE approach

Monitor SpO2 and give oxygen if hypoxic
Monitor ECG and BP, and record 12-lead ECG
Obtain IV access
Identify and treat reversible causes (e.g.
electrolyte abnormalities)

Adverse features?
Shock Myocardial ischaemia
Syncope Heart failure

Yes No

Atropine 500 mcg IV

Satisfactory response?

No Yes

Consider interim measures:

Atropine 500 mcg IV repeat to
Risk of asystole?
maximum of 3 mg
Recent asystole
OR Yes Mobitz II AV block
Transcutaneous pacing
Complete heart block with
OR
broad QRS
Isoprenaline 5 mcg min-1 IV
Ventricular pause > 3 s
Adrenaline 2-10 mcg min-1 IV
Alternative drugs* No

Seek expert help ! Continue observation

Arrange transvenous pacing

* Alternatives include:
Aminophylline
Dopamine
Glucagon (if bradycardia is caused by beta-blocker or calcium channel blocker)
Glycopyrrolate (may be used instead of atropine)

Resuscitation Council Guidelines 2015 - due for update in 2020

 


Adrenaline 1:1000
1mg/ml

Indication:

Anaphylaxis & hypersensitivity reactions

‣ If you suspect anaphylaxis, always start with IM adrenaline
‣ Adrenaline is the only drug that can stop an anaphylactic reaction (the other
drugs only ameliorate the effects)

Dose Where to find it

‣ 500 micrograms (0.5ml) IM ‣ ACU stock

‣ Repeat after 5 minutes if no
How to prepare the drug
better

How to administer the drug ‣ No prep required: draw

up and inject IM.
‣ Intramuscular injection

Monitoring required

‣ Anaphylaxis is a potentially
life threatening emergency:
full monitoring and repeat
obs every 5-10 minutes until
reaction has settled.

Other drugs you will need

‣ Chlorphenamine
‣ Hydrocortisone
‣ Hartmanns or N/Saline

ACU Emergency Drugs File Working Draft v1.0 April 2020

 


Chlorphenamine
Indication:

Anaphylaxis & hypersensitivity reactions

‣ If you suspect anaphylaxis, always start with IM adrenaline
‣ Adrenaline is the only drug that can stop an anaphylactic reaction (the other
drugs, including chlorphenamine, only ameliorate the effects)

Dose Where to find it

‣ 10mg ‣ ACU stock

How to administer the drug How to prepare the drug

‣ Slow IV injection over at least ‣ Dilute up to 10ml using N/

one minute Saline
Monitoring required

‣ Anaphylaxis is a potentially life

threatening emergency: full
monitoring and repeat obs
every 5-10 minutes until
reaction has settled.
Other drugs you will need

‣ ADRENALINE
‣ Hydrocortisone
‣ Hartmanns or N/Saline

ACU Emergency Drugs File Working Draft v1.0 April 2020

 


Hydrocortisone as sodium
succinate

Indication:

Anaphylaxis & hypersensitivity reactions

‣ If you suspect anaphylaxis, always start with IM adrenaline
‣ Adrenaline is the only drug that can stop an anaphylactic reaction (the other
drugs, including chlorphenamine, only ameliorate the effects)

Dose Where to find it

‣ 200mg ‣ ACU stock

How to administer the drug How to prepare the drug

‣ Slow IV injection over 1-10 mins ‣ Reconstitute each vial

using 2ml of water for
Monitoring required injections, and shake the
vial until the solution is
‣ Anaphylaxis is a potentially life
clear
threatening emergency: full
‣ Then dilute to 10ml in N/
monitoring and repeat obs
Saline to aid slow
every 5-10 minutes until
administration
reaction has settled.
Other drugs you will need

‣ ADRENALINE
‣ Chlorphenamine
‣ Hartmanns or N/Saline

ACU Emergency Drugs File Working Draft v1.0 April 2020

Anaphylaxis
Resuscitation Council (UK)

Anaphylactic reaction?

Airway, Breathing, Circulation, Disability, Exposure

Diagnosis - look for:

• Acute onset of illness
• Life-threatening Airway and/or Breathing
1
and/or Circulation problems
• And usually skin changes

• Call for help

• Lie patient flat
• Raise patient’s legs

2
Adrenaline

When skills and equipment available:

• Establish airway
• High flow oxygen Monitor:
3
• IV fluid challenge • Pulse oximetry
4
• Chlorphenamine • ECG
5
• Hydrocortisone • Blood pressure

1 Life-threatening problems:
Airway: swelling, hoarseness, stridor
Breathing: rapid breathing, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion
Circulation: pale, clammy, low blood pressure, faintness, drowsy/coma

2 Adrenaline (give IM unless experienced with IV adrenaline) 3 IV fluid challenge:

IM doses of 1:1000 adrenaline (repeat after 5 min if no better) Adult - 500 – 1000 mL
• Adult 500 micrograms IM (0.5 mL) Child - crystalloid 20 mL/kg
• Child more than 12 years: 500 micrograms IM (0.5 mL)
Stop IV colloid
• Child 6 -12 years: 300 micrograms IM (0.3 mL)
if this might be the cause
• Child less than 6 years: 150 micrograms IM (0.15 mL) of anaphylaxis
Adrenaline IV to be given only by experienced specialists
Titrate: Adults 50 micrograms; Children 1 microgram/kg

4 Chlorphenamine 5 Hydrocortisone
(IM or slow IV) (IM or slow IV)
Adult or child more than 12 years 10 mg 200 mg
Child 6 - 12 years 5 mg 100 mg
Child 6 months to 6 years 2.5 mg 50 mg
Child less than 6 months 250 micrograms/kg 25 mg

Figure 3. Anaphylaxis algorithm

Resuscitation20Council website
EMERGENCY accessed
TREATMENT Feb 2020; “Emergency
OF ANAPHYLACTIC REACTIONS Treatment of anaphylactic
reactions” still current despite “… review date of 2013 has been extended to 2017”.
Glucose 10/20%



Indication:

Hypoglycaemia (severe) in diabetes

‣ Unconscious ‣ Aggressive
‣ Fitting ‣ Nil by Mouth

Dose Where to find it

‣ 150ml of 10% glucose ‣ ACU Drug cupboard

or
‣ 75-100ml of 20% glucose (in How to prepare the drug
large vein, followed by N/Saline
flush) ‣ n/a
‣ Repeat up to 3x if still NB: If no IV access, give
hypoglycaemic 10 minutes after Glucagon 1mg IM.
each dose

How to administer the drug

‣ Give over 10-15 minutes

‣ Use infusion pump if available
(but do not delay treatment to do so)

Monitoring required

‣ Check fingerpick blood glucose

10 minutes after the dose

Other drugs you will need

‣ Carbohydrate source

ACU Emergency Drugs File Working Draft v1.0 April 2020

 BCUHB Algorithm for the Hospital Management of Hypoglycaemia in Adults with Diabetes
Hypoglycaemia = Blood Glucose of less than 4mmol/L
(if not less than 4mmol/L but symptomatic; give a small carbohydrate snack for symptom relief)
Mild Moderate Severe
Patient is conscious, orientated and able to swallow Patient is conscious, able to swallow but is Patient unconscious, fitting, aggressive or nil by mouth (NBM)
(OR conscious, NBM but with functioning NG or PEG in situ) confused and unable to co-operate (if unconscious follow Resus Guidelines)

Give 15-20g quick-acting carbohydrate as: Give 1.5–2 tubes Dextrogel®/GlucoGel® Check ABC. Stop any IV insulin and fast bleep doctor
(contents of each tube (10g glucose) to be squeezed between If NO IV access: Give 1mg Glucagon* IM (only to be given once)
1 x 60mL bottle GlucoJuice® (15g)
teeth & gums and outside of cheek rubbed gently)
200mL pure fruit juice e.g. Orange (20g)
If IV access: Give IV glucose infusion over 10-15 minutes as:
TEST BLOOD GLUCOSE AFTER 15 MINUTES TEST BLOOD GLUCOSE AFTER 15 MINUTES
75-100mL of 20% glucose (in large vein + sodium chloride 0.9% flush)
Hypoglycaemia

OR Use infusion pump if available

150mL of 10% glucose Use
but infusion
do not delay available
pump iftreatment
If still less than 4mmol/L repeat If still less than 4mmol/L repeat
but do not delay treatment
above treatment (up to max 3 times) above treatment (up to max 3 times) OR
30mL of 50% glucose (in large vein + sodium chloride 0.9% flush)

If above ineffective, consider 1mg TEST BLOOD GLUCOSE AFTER 10 MINUTES

If still hypoglycaemic or deteriorating glucagon* IM (only to be given once) or
at any stage, call doctor and consider if still hypoglycaemic or deteriorating
If blood If blood If blood
IV glucose (as for severe) or 1mg at any stage, call doctor and consider If still hypoglycaemic, repeat above IV treatment up
glucose glucose glucose
glucagon* IM (only to be given once) IV glucose (as for severe) to max 3 times then start IV 10% glucose infusion
≥4mmol/L ≥4mmol/L ≥4mmol/L

or
Blood glucose level should now be above 4mmol/L Give 20g of long-acting carbohydrate: e.g. 2 crackers, slice of bread, 300mL glass of milk OR next meal if due .
If IM Glucagon* has been administered then give 40g long-acting carbohydrate to replenish glycogen stores.
For Enterally fed patients ONLY: restart feed OR give bolus feed OR start IV 10% glucose infusion at 100mL/hr
If ‘Nil by mouth’ (NBM) then once blood glucose is greater than 4mmol/L - give IV 10% glucose infusion at 100mL/hr until no longer NBM or reviewed by doctor.

If HYPO due to sulphonylurea (e.g. gliclazide) or long-acting insulin, risk of hypoglycaemia may persist for 24-36 hours especially in renal impairment – consider IV 10% glucose infusion 100mL/hr
Do NOT omit subsequent doses of insulin. Continue regular capillary blood glucose monitoring for 24-48 hours. Review insulin/oral hypoglycaemic doses. Refer to Diabetes Team for severe
or repeated HYPOs. Always use the HYPO STICKER – record in medical notes. Reference: Hospital Management of Hypoglycaemia in Adults with Diabetes - Sept 2013

*Glucagon may take up to 15 minutes to take effect & may be less effective in patients with liver disease, glucocorticoid deficiency, those chronically malnourished or starved with depleted
glycogen stores (hence only given once per hypo episode) and in patients prescribed sulphonylurea therapy e.g. Gliclazide. J Walker & BCUHB Diabetes Teams: March 2018: Version 3
BCUHB 2018 Guidelines
GTN patches
Indication:
1. Pulmonary oedema
2. Persistent cardiac chest pain
This community hospital pathway uses GTN patches as an
alternative to GTN infusion, pending and during transfer.

Dose Where to find it

‣ Start dose* is a 10mg-per-24-hour ‣ LLGH Emergency Drug

plus a 5mg-per-24-hour patch: Cupboard
this delivers 625 micrograms of
GTN per hour in total (this is very How to prepare the drug
close to the 600 mcg/hour typical
starting dose of a GTN infusion). ‣ See packaging
‣ Onset time is 30-60 minutes, so
expect to use 1-2 puffs of GTN Other drugs you will need
sub-lingual spray every 15-20
minutes whilst the patches take ‣ In acute pulmonary oedema:
effect. furosemide 40mg** IV.
‣ In persistent cardiac chest
How to administer the drug pain: morphine (10mg in 10ml
‣ Apply to a clean, dry, hairless area and titrate slowly IV) & aspirin
of skin (e.g. lateral chest wall) 300mg to chew. The YGC chest
pain nurse may request
Monitoring required additional interventions.
‣ ECG & sats monitoring; BP and NB: DO NOT USE OPIATES IN SEVERE
pulse every 10-15 mins PULMONARY OEDEMA unless in a
‣ Aim to keep systolic BP above palliative care situation
110mmHg: remove one of the
patches if BP falls below this.
*If patient is known to be intolerant of
‣ Pain score every 15 minutes where sensitive to nitrates, start with a 10mg-per-24-
applicable hour patch by itself.
**May need a higher dose if already on
furosemide

ACU Emergency Drugs File Working Draft v1.0 April 2020

Lorazepam



Indication:

Status Epilepticus
Dose Where to find it

‣ 4mg IV bolus ‣ TBC

‣ Give another 4mg IV bolus ‣ In the fridge
10-20 minutes after the first
How to prepare the drug
dose of Lorazepam (or other
benzodiazepine) if seizure does
‣ Comes as 4mg in 1ml, in a
not stop/if it recurs 2ml vial
‣ Dilute with 1ml of N/Saline
How to administer the drug
What to expect
‣ Slow IV (or IO) bolus ‣ Often causes marked
drowsiness
Monitoring required ‣ May cause respiratory
depression - have bag-valve-
‣ Full monitoring (including ECG) mask available
‣ Check blood glucose

Other drugs you will need

‣ No other anticonvulsants
available in LLGH
‣ Pabrinex & Glucose 10/20% if
any suspicion of alcohol abuse or
impaired nutrition
‣ Alternative benzodiazepines are
buccal midazolam (10mg) or
rectal diazepam (10-20mg)

ACU Emergency Drugs File Working Draft v1.0 April 2020

Pabrinex



Indication:
If any suspicion of alcohol abuse or
1. Status Epilepticus malnutrition

2. Chronic alcoholism Where there is a risk of Wernicke’s

encephalopathy

Dose Where to find it

‣ 2 pairs of 5ml ampoules (where ‣ TBC

one pair = ampoule 1 +
ampoule 2) How to prepare the drug

How to administer the drug ‣ Mix the contents of

ampoules 1 & 2
‣ IV infusion over 30 minutes ‣ Add to 100ml N/Saline

Monitoring required

‣ Full monitoring if in status

epilepticus
‣ 15-minute obs during infusion
in non-status epilepticus
situations

Other drugs you will need

In status epilepticus:
‣ Lorazepam
‣ Glucose 10/20% (dose as per
Hypoglycaemia guideline)
‣ Alternative benzodiazepines are
buccal midazolam (10mg) or
rectal diazepam (10-20mg)

ACU Emergency Drugs File Working Draft v1.0 April 2020

Status Epilepticus
Ysbyty Gwynedd Emergency Department (with minor adaptations for LLGH ACU)

Status Epilepticus - Adults

Status epilepticus is a serious problem. Call for back-up (senior ED doctor in hours;
anaesthetic & medical registrar out of hours) if patient still fitting after 2nd dose
! lorazepam. Always be prepared to proceed to next step in the pathway without delay. !

0-10 mins Lorazepam 4mg IV

(if no IV access, use midazolam 10mg buccal or diazepam 10-20mg rectal)
ABC High flow oxygen* IV access
Support airway - consider Check BM urgently Bloods
NP/OPA Full set observations Estimate patient’s weight

If seizures don’t stop or if they recur…

Request urgent ambulance transfer to ED ◉ Alert receiving ED’s Nurse in Charge (inc. pt weight)

10-20 mins Lorazepam 4mg IV (10-20 minutes after 1st dose of benzodiazepines)
- May be given IO if required
- Alert the receiving ED that they need to start preparing Phenyotin or equivalent to give on
patient arrival if seizure continues at that point

Monitoring Consider non- Give IV Glucose (dose as per BCUHB

Bloods (if not already) epileptic status Hypoglycaemia protocol) and/or IV thiamine
ABG (if not already) (250mg) as high-potency IV Pabrinex if any
suspicion alcohol abuse/impaired nutrition

Remainder of the Status Epilepticus protocol cannot be delivered in a community hospital

30 mins Phenytoin 15mg/kg** - infuse at 50mg/min

Must be commenced by 30 minutes. Call ITU team if seizures continue

Establish aetiology Ask ITU team to come to Inform medical consultant

Treat medical complications resus (if not already present) on-call of the patient.

If seizures don’t stop or if they recur…

NB: Medical consultant
on-call must be involved
in the referral to ITU
60-90 mins General anaesthesia & transfer to ITU

Investigations Monitoring
• ABG (or venous gas if ABG not possible) • Neuro observations
• FBC, U&E, LFT • Pulse/BP/RR/Temperature
• Calcium & magnesium • Sats
• Anticonvulsant levels (if appropriate) • ECG by monitor
• INR (if on warfarin)
• CXR (in case of aspiration)
• 12-lead ECG once fit stops NOTES SpO2 of 94-98% (88-92%
* Oxygen can be stopped/ if pre-existing lung disease)
• Possibly CT and/or LP as directed by
titrated once seizure ** Note change in Phenytoin
senior staff: out of hours, arrange via finishes as per BTS dose to 15mg/kg (previously
medical registrar. guidelines, aiming for 18mg/kg)

v1.1 - June 2012 - Dr Rob Perry Adapted from the 2012 NICE Guideline CG137 (Appendix F)
Updated Feb 2020 for use in LLGH ACU Emergency Drugs File by Dr Linda Dykes
Magnesium

 as magnesium sulphate heptahydrate
1g ≈ 4 mmol Mg2+

Indication:
1. Hypomagnesaemia (severe)
2. Torsades de pointes (regardless of serum Mg2+)
3. Acute severe asthma

Dose & Administration Where to find it

1. Hypomagnesaemia ‣ Magnesium sulphate 50%

‣ 2g-4g (8-16 mmol Mg2+) given over (20mmol in 10ml) in the
60 minutes Emergency Drugs Cupboard

2. Torsade de pointes How to prepare the drug

‣ 2g (8 mmol Mg2+) over 10 mins Instructions given here are for a 2g dose
(may be repeated once)
‣ Dilute 2g/8 mmol (= 4ml of
3. Acute Severe Asthma magnesium sulphate 50%) in
‣ 1.2-2g over 20 mins 100ml of N/Saline
‣ Administer via infusion pump at
Monitoring required
the specified rate for the relevant

‣ Give in resus with full monitoring indication (see left)

‣ Measure urine output Other drugs you will need
‣ Watch for signs of Mg2+ overdose:
- Loss of patella reflexes
‣ In Acute Severe Asthma:
- Weakness
- Nausea salbutamol & ipatropium nebs,
- Sensation of warmth prednisolone or hydrocortisone,
- Flushing and consider IM adrenaline 0.5mg
- Drowsiness
if any suspicion of anaphylaxis.
- Double vision
- Slurred speed ‣ In Torsade de pointes: you will
need IV Potassium if patient is
hypokalaemic on iSTAT.

ACU Emergency Drugs File Working Draft v1.0 April 2020

Hypomagnesaemia (low magnesium)

Ysbyty Gwynedd Emergency Department & MEC In all cases of

hypomagnesaemia:

Low magnesium • Stop PPI

• Review diuretics

• Hypomagnesaemia is common patients with low magnesium may • Hypomagnesaemia is often

(7-11% of hospital patients, 2% of just feel weak. associated with hypokalaemia and
background population & 65% of • Diuretics, excess alcohol, PPIs hypocalcaemia - check!
critically ill patients & diarrhoea are common culprits • Low magnesium needs to be
• You need to specifically request • The definition is serum corrected before low potassium
magnesium levels if you suspect it magnesium <0.7 mmol/L (normal and calcium will respond to
• Textbook descriptions are range 0.7-1.4 mmol/L) treatment
dramatic (paraesthesia, tetany, • ↓Mg2+ is not usually symptomatic • Most patients can be treated with
arrythmias, seizures), but elderly until levels fall before 0.5 mmol/L oral magnesium supplementation

When to check 1. Elderly and unwell - especially if ℅ 2. On finding hypokalaemia or

weakness, on PPI or diuretics, excess hypocalcaemia (low Mg2+
magnesium: EtOH, or history of recent diarrhoea unlikely if K+/Ca2+ normal)

Mild (0.50-0.70 mmol/L) Low serum Mg <0.40 mmol/L

and symptomatic Mg2+ (or 0.40-0.49 mmol/L and
or (yellow bottle) highly symptomatic,
Moderate (0.40-0.49) e.g. paraesthesia, tetany, seizures)
even if asymptomatic See bottom box for arrhythmias
or admission refused by patient
or admission not considered in
patient’s best interest
Intravenous magnesium
supplementation indicated
Oral magnesium supplementation (NB IM route can also be used)
for 5-7 days (then recheck levels)
• Initial dose is 2g-4g of magnesium
sulphate (= 8-16 mmol Mg2+) IV given
• Magnesium aspartate 1-2 sachets/
over one hour
day (one 6.5g sachet = 10 mmol Mg2+)
Reduce dose • Up to 40g may be needed over next five
• Maalox® 10-20ml QDS
in renal days
(10 ml Maalox = 6.8 mmol Mg)
• Magnesium glycerophosphate
impairment. EASY STARTING DOSE IN ED:
Seek expert 2 or 2.5g (whichever is easiest to draw up)
(Neomag®)1-2 tabs TDS (4mmol Mg/
advice if in ≥100ml of normal saline, over 60 mins
tab)
eGFR <30.

How to give IV magnesium Whilst giving IV Magnesium:

• Give in resus area if possible
• It’s magnesium sulphate heptahydrate
• Monitor BP, RR, urine output
• 1g is equivalent to Mg2+ of approx 4 mmol • Watch for signs of overdose:
• The solution in the vials needs to be diluted before use: loss of patellar reflexes,
concentration should not exceed 200mg/ml (= 0.8 mmol/mL) Mg2+ weakness, nausea, sensation of
• Dilute 1 part MgSO4 50% with at least 1.5 parts of water for warmth, flushing, drowsiness,
injections (NB it can also be diluted in 5% glucose or N/S) double vision, slurred speech

IV magnesium in other conditions: an aide memoire

• Arrhythmias (eg Torsades) 2g (8mmol) over 10-15min (may be repeated once)
v2.0 - August 2018 - LD/AW/NK • Acute Severe Asthma 1.2-2g (4.8-8 mmol) over 20 mins
Revision date April 2020 • Eclampsia 4g (16 mmol) over 5-15 mins, then infusion
Torsades de pointes



From ALS 2015 - Peri-Arrest Arrythmia chapter

Treat torsade de pointes VT immediately by:

• Stopping all drugs known to prolong the QT interval.

• Do not give amiodarone for definite torsade de pointes.

• Correct electrolyte abnormalities, especially hypokalaemia.

• Give magnesium sulfate 2g IV over 10 min (= 8 mmol, 4 mL of 50%

magnesium sulfate).

• Obtain expert help, as other treatment (e.g. overdrive pacing) may be

indicated to prevent relapse once the arrhythmia has been corrected.
➡The defibrillator in LLGH ECG room has pacing functionality

• If adverse features (shock, syncope, myocardial ichaemia, or heart failure)

are present, which is common, arrange immediate synchronised
cardioversion.
➡Start with 120-150J (as per for broad-complex tachycardias)
➡Ensure the defibrillator is set to synchronised mode

• If the patient becomes pulseless, attempt defibrillation immediately (follow

ALS algorithm).

ACU Emergency Drugs File Working Draft v1.0 April 2020

 MANAGEMENT OF ACUTE ASTHMA IN ADULTS MANAGEMENT OF ACUTE ASTHMA IN ADULTS

ASSESSMENT OF SEVERE ASTHMA CRITERIA FOR ADMISSION

B Admit patients with any feature of a life-threatening or near-fatal asthma attack.

B Healthcare professionals must be aware that patients with severe asthma and one or more
adverse psychosocial factors are at risk of death. B Admit patients with any feature of a severe asthma attack persisting after initial treatment.

INITIAL ASSESSMENT C Patients whose peak flow is greater than 75% best or predicted one hour after initial treatment
may be discharged from ED, unless there are other reasons why admission may be appropriate.
MODERATE ACUTE ASTHMA LIFE-THREATENING ASTHMA
TREATMENT OF ACUTE ASTHMA

y increasing symptoms In a patient with severe asthma any one of: OXYGEN β2 AGONIST BRONCHODILATORS
y PEF <33% best or predicted
y PEF >50–75% best or predicted y SpO2 <92% y Give controlled supplementary oxygen A Use high-dose inhaled β2 agonists as first-
C line agents in patients with acute asthma
y no features of acute severe asthma y PaO2 <8 kPa to all hypoxaemic patients with acute
severe asthma to maintain an SpO2 and administer as early as possible. Reserve
y normal PaCO2 (4.6–6.0 kPa)
level of 94–98%. Do not delay oxygen intravenous β2 agonists for those patients
ACUTE SEVERE ASTHMA y silent chest in whom inhaled therapy cannot be used
administration in the absence of pulse
y cyanosis oximetry but commence monitoring of reliably.
y poor respiratory effort SaO2 as soon as it becomes available.
In patients with acute asthma with life-
Any one of: y arrhythmia
A y In hospital, ambulance and primary threatening features the nebulised route
y exhaustion care, nebulisers for giving nebulised β2 (oxygen-driven) is recommended.
y PEF 33–50% best or predicted
y altered conscious level agonist bronchodilators should preferably
y respiratory rate ≥25/min y hypotension be driven by oxygen. A In patients with severe asthma that is poorly
responsive to an initial bolus dose of β2
y heart rate ≥110/min STEROID THERAPY agonist, consider continuous nebulisation
NEAR-FATAL ASTHMA
y inability to complete sentences in one breath with an appropriate nebuliser.
Raised PaCO2 and/or requiring mechanical A Give steroids in adequate doses to all
patients with an acute asthma attack. IPRATROPIUM BROMIDE
ventilation with raised inflation pressures
Continue prednisolone (40–50 mg daily) for B Add nebulised ipratropium bromide (0.5
INITIAL ASSESSMENT OF SYMPTOMS, SIGNS AND MEASUREMENTS
at least five days or until recovery. mg 4–6 hourly) to β2 agonist treatment
Clinical Severe breathlessness (including too breathless to complete sentences in one breath), for patients with acute severe or life-
OTHER THERAPIES
features tachypnoea, tachycardia, silent chest, cyanosis or collapse threatening asthma or those with a poor
A Nebulised magnesium sulphate is not initial response to β2 agonist therapy.
None of these singly or together is specific and their absence does not exclude a severe
attack recommended for treatment in adults with
REFERRAL TO INTENSIVE CARE
acute asthma.
PEF or FEV1 PEF or FEV1 are useful and valid measures of airway calibre. PEF expressed as a % of Refer any patient:
the patient’s previous best value is most useful clinically. In the absence of this, PEF B Consider giving a single dose of IV y requiring ventilatory support
as a % of predicted is a rough guide magnesium sulphate to patients with acute
severe asthma (PEF <50% best or predicted) y with acute severe or life-threatening asthma, who
Pulse Oxygen saturation (SpO2) measured by pulse oximetry determines the adequacy of who have not had a good initial response to is failing to respond to therapy, as evidenced by:
oximetry oxygen therapy and the need for arterial blood gas measurement (ABG). The aim of inhaled bronchodilator therapy. - deteriorating PEF
oxygen therapy is to maintain SpO2 94–98% - persisting or worsening hypoxia
Magnesium sulphate (1.2–2 g IV infusion over - hypercapnia
Blood gases Patients with SpO2 <92% or other features of life-threatening asthma require ABG 20 minutes) should only be used following - ABG analysis showing pH or H+
(ABG) measurement consultation with senior medical staff.
- exhaustion, feeble respiration
B Routine prescription of antibiotics is not - drowsiness, confusion, altered conscious state
Chest X-ray Chest X-ray is not routinely recommended in patients in the absence of:
indicated for patients with acute asthma. - respiratory arrest.
- suspected pneumomediastinum or pneumothorax
FOLLOW UP
- suspected consolidation
y It is essential that the patient’s primary care practice is informed within 24 hours of discharge
- life-threatening asthma from the emergency department or hospital following an asthma attack.
- failure to respond to treatment satisfactorily y Keep patients who have had a near-fatal asthma attack under specialist supervision indefinitely.
y A respiratory specialist should follow up patients admitted with a severe asthma attack for at
- requirement for ventilation least one year after the admission.
Acute Severe Asthma (2019 BTS Guidelines)

16 Applies only to adults Applies to children ≥1 Applies to children 5-12 Applies to children under 5 General Applies to adolescents

Applies only to adults Applies to children ≥1 Applies to children 5-12 Applies to children under 5 General Applies to adolescents 15
 


Tazocin Piperacillin with tazobactam

® CONTAINS A PENICILLIN

Indication:

Severe Sepsis of unknown source

‣ As per Microguide empirical treatment for Severe Sepsis

Dose Where to find it

‣ 4.5g ‣ LLGH Emergency Drug

Cupboard
How to administer the drug
How to prepare the drug
‣ Infuse over 30 minutes
‣ Reconstitute the 4.5g vial
Monitoring required with 20ml of water for
‣ None required for the drug per injections or N/Saline.
se, but sick patient will need ‣ Swirl until dissolved (5-10
obs every 15-30 minutes minutes)
pending transfer. ‣ Dilute into 100ml N/Saline

Other drugs you will need

‣ Hartmanns (or Normal Saline)

for fluid bolus

ACU Emergency Drugs File Working Draft v1.0 April 2020

 


Vancomycin (loading dose only)

Indication:

Severe Sepsis + penicillin allergy

‣ As per Microguide empirical treatment for Severe Sepsis
‣ This page applies to the initial loading dose only.

Dose Where to find it

‣ Under 60kg - 1g ‣ LLGH Emergency Drug
‣ 60 to 90kg - 1.5g Cupboard
‣ Over 90kg - 2g
How to administer the drug How to prepare the drug

By infusion: ‣ Reconstitute using water

‣ 1g over 120 minutes for injections (use 10ml per
‣ 1.5g over 180 minutes 500mg of vancomycin)
‣ 2g over 240 minutes ‣ Then add to N/Saline
500ml
Monitoring required
‣ Infuse at the rates stated in
‣ None required for the drug per “How to administer the
se, but sick patient will need drug” (see ⬉)
obs every 15-30 minutes
pending transfer.
Other drugs you will need

‣ Ciprofloxacin 400mg IV
(from LLGH Emergency
Cupboard)
‣ Hartmanns (or Normal Saline)
for fluid bolus

ACU Emergency Drugs File Working Draft v1.0 April 2020

Ciprofloxacin



Indication:

Severe Sepsis + penicillin allergy

‣ As per Microguide empirical treatment for Severe Sepsis
‣ For other situations, oral ciprofloxacin is likely to be adequate

Dose Where to find it

‣ 400mg ‣ LLGH Emergency Drug
Cupboard
How to administer the drug
How to prepare the drug
By infusion over 60 minutes, into
a large peripheral vein if possible ‣ Ciprofloxacin for injection
Monitoring required comes ready-mixed

‣ None required for the drug per

se, but a sick patient will need
obs every 15-30 minutes
pending transfer.
Other drugs you will need

‣ Vancomycin (from LLGH

Emergency Cupboard)
‣ Hartmanns (or Normal Saline)
for fluid bolus

ACU Emergency Drugs File Working Draft v1.0 April 2020

Severe Sepsis: definitions
Does the patient have Severe Inflammatory Response
1 Syndrome (SIRS)?
Two or more of:
• Temp >38.3 or <36°C
• Heart Rate >90 bpm
• WCC >12 or <4
• Neutrophils <1
• Alertness Acutely altered mental state
• Glucose >6.6mmol/L in non-diabetic patients

Yes No

Does the patient have

Patient does not
2 a suspected or proven
infection?
No
have sepsis

Yes

Patient has sepsis.

3 But are any criteria for SEVERE sepsis present?
Any one of:
• BP Systolic <90 or MAP <65 mmHg
• Sats Need oxygen to maintain SaO2 >90%
• Lactate >2mmol/l
• Urine output <0.5ml/kg/hour for 2 or more hours
• Creatinine Acute rise in creatinine to >177µmol/L
• Bilirubin >34 µmol/L
• Coag INR >1.5 or APTT >60
• Platelets <100 x 1012/L

No Yes
Treat as per clinical “Sepsis Six”
judgement bundle indicated
 4 Vulnerable – While not dependent on others for
daily help, often symptoms limit activities. A common
complaint is being “slowed up”, and/or being tired
during the day.

5 Mildly Frail – These people often have more

evident slowing, and need help in high order IADLs
(finances, transportation, heavy housework, medica-
tions). Typically, mild frailty progressively impairs
shopping and walking outside alone, meal preparation
and housework.

6 Moderately Frail – People need help with all

outside activities and with keeping house. Inside, they
often have problems with stairs and need help with
bathing and might need minimal assistance (cuing,
standby) with dressing.

Top Tips to help you use the

Clinical Frailty Scale*
7 Severely Frail – Completely dependent for
1 Very Fit – People who are robust, active, energetic personal care, from whatever cause (physical or
and motivated. These people commonly exercise cognitive). Even so, they seem stable and not at
regularly. They are among the fittest for their age. high risk of dying (within ~ 6 months).

2 Well – People who have no active disease 8 Very Severely Frail – Completely dependent,
symptoms but are less fit than category 1. Often, they approaching the end of life. Typically, they could
exercise or are very active occasionally, e.g. seasonally. not recover even from a minor illness.

3 Managing Well – People whose medical problems

are well controlled, but are not regularly active
beyond routine walking. 9. Terminally Ill - Approaching the end of life. This
Participating Sites:

Clinical Frailty Scale

category applies to people with a life expectancy
4 Vulnerable – While not dependent on others for <6 months, who are not otherwise evidently frail.
daily help, often symptoms limit activities. A common
complaint is being “slowed up”, and/or being tired Scoring frailty in people with dementia
during the day. The degree of frailty corresponds to the degree of dementia.
Common symptoms in mild dementia include forgetting the
5 Mildly Frail – These people often have more details of a recent event, though still remembering the event itself,
evident slowing, and need help in high order IADLs repeating the same question/story and social withdrawal.
(finances, transportation, heavy housework, medica-
tions). Typically, mild frailty progressively impairs In moderate dementia, recent memory is very impaired, even
shopping and walking outside alone, meal preparation though they seemingly can remember their past life events well.
Cape Breton District

and housework. They can do personal care with prompting. HEALTH AUTHORITY
M a k i n g H e a l t h i e r C h o i c e s To g e t h e r

In severe dementia, they cannot do personal care without help.

6 Moderately Frail – People need help with all
* 1. Canadian Study on Health & Aging, Revised 2008.
Sponsors:
outside activities and with keeping house. Inside, they 2. K. Rockwood et al. A global clinical measure of fitness and
often have problems with stairs and need help with frailty in elderly people. CMAJ 2005;173:489-495.
bathing and might need minimal assistance (cuing,
© 2007-2009. Version 1.2. All rights reserved. Geriatric Medicine
standby) with dressing. Research, Dalhousie University, Halifax, Canada. Permission granted
to copy for research and educational purposes only.

7 Severely Frail – Completely dependent for

personal care, from whatever cause (physical or

The Clinical Frailty Scale (CFS) was designed to summarise the results of
cognitive). Even so, they seem stable and not at
high risk of dying (within ~ 6 months).

8 Very Severely Frail – Completely dependent,

approaching the end of life. Typically, they could
not recover
© 2007-2009. even1.2.
Version from
Allarights
minorreserved.
illness. Geriatric Medicine Research, Dalhousie University, Halifax, Canada.
Permission granted to copy for research and educational purposes only.

a Comprehensive Geriatric Assessment. It’s now commonly being used as a triage

9. Terminally Ill - Approaching the end of life. This
category applies to people with a life expectancy
<6 months, who are not otherwise evidently frail.

Scoring frailty in people with dementia

The degree of frailty corresponds to the degree of dementia.
Common symptoms in mild dementia include forgetting the
details of a recent event, though still remembering the event itself,
repeating the same question/story and social withdrawal.

tool to make important clinical decisions, so it is imperative that it is used correctly.

In moderate dementia, recent memory is very impaired, even
though they seemingly can remember their past life events well.
They can do personal care with prompting.
In severe dementia, they cannot do personal care without help.

* 1. Canadian Study on Health & Aging, Revised 2008.

2. K. Rockwood et al. A global clinical measure of fitness and
frailty in elderly people. CMAJ 2005;173:489-495.

#1
2007-2009. Version 1.2. All rights reserved. Geriatric Medicine Research, Dalhousie University, Halifax, Canada.
It's all about the baseline #6 Having medical problems does not
If the person you are assessing is acutely automatically increase the score to CFS 3
ermission granted to copy for research and educational purposes only.

unwell, score how they were 2 weeks ago, A person who isn't bothered by symptoms and
not how they are today. whose condition(s) doesn't limit their lives can
be CFS 1 or 2 if they’re active and independent.

#2 You must take a proper history

The CFS is an objective clinical assessment Don’t forget “vulnerable” (CFS 4)
#7
tool. Frailty must be sensed, described, and People in this category are not dependent
measured - not guessed. (though they may need assistance with heavy
housework), but often complain of "slowing
Trust, but verify down”. They’re becoming sedentary, with
#3
What the person you are assessing says is poor symptom control.
important, but should be cross-referenced
with family/carers. The CFS is a judgement-
#8 Dementia doesn’t limit use of the CFS
based tool, so you must integrate what
Decline in function in people living with
you are told, what you observe, and what
dementia follows a pattern similar to frailty,
your professional clinical experience tells
so if you know the stage of dementia (mild,
you from dealing with older adults
moderate, severe) you know the level of
frailty (CFS 5,6,7). If you don’t know the stage
#4 Over-65s only of dementia, follow the standard CFS scoring.
The CFS is not validated in people under
65 years of age, or those with stable single-
#9
Drill down into changes in function
system disabilities. However, documenting
When considering more complex activities of
how the person moves, functions, and has daily living (such as cooking, managing
felt about their health may help to create an
finances, and running the home) the focus is
individualised frailty assessment. on change in function. A person who has
always relied on someone else to perform a
Terminally ill (CFS 9) particular activity should not be considered
#5
For people who appear very close to dependent for that activity if they’ve never
death, the current state (i.e. that they are had to do it before and may not know how.
dying) trumps the baseline state.
Kenneth Rockwood, Sherri Fay, Olga Theou & Linda Dykes
v1.0 9 April 2020