There is currently a national shortage of Intranasal Diamorphine therefore we are using Intranasal Fentanyl as a replacement.
Dose is 1.5micrograms/Kg for the initial dose and 0.75micrograms/kg 10 minutes later if required.
Draw up the appropriate dose plus 0.1ml to allow for the dead space in the Mucosal Atomizer Device
Attach the MAD to the syringe
Sit the child at 45 degrees insert MAD loosely into the nostril and press the plunger
Doses greater than 0.5ml should be split between 2 nostrils
- Blocked nose due to upper respiratory illness or epistaxis
- Respiratory depression
- Altered consciousness
- Hypersensitivity to fentanyl
- Children below 1 year old
Full Intranasal Fentanyl SOP
Penthrox is an inhaled, patient controlled analgesic for use with moderate to severe acute pain associated with trauma. Not to be used in atraumatic pain, chronic pain, children or pregnancy.
Rapid onset of analgesia lasting 25-60 minutes depending on rate and depth of inhalation. Wears off 10 minutes after last inhalation.
Contraindications (CHECK ALLL):
Studies suggest around 1% of hip fractures are missed on plain X-ray. So as usual you must combine clinical and radiological findings. Read more
We are regularly doing femoral blocks next to major vessels. So warn the patient of the symptoms, & keep them monitored(at least 15 min).
Symptoms of local anaesthetic toxicity
- Circumoral and/or tongue numbness
- Metallic taste
- Visual/Auditory disturbances (blurred vision/tinnitus)
- Cardio-Resp Arrest
Remember – Do basics WELL
Intralipid – in antidote cupboard (Green Majors treatment room)
- Bolus – 1.5ml/kg 20% lipid solution over 1min
- Then start Infusion – 15ml/kg/hr 20% lipid solution
- 5 mins reassess if Cardiac instability/deterioration
- Rpt Bolus 1.5ml/kg over 1min (max 3 boluses inc. initial)
- Increase infusion rate – up to 30ml/kg/hr
- Total Max dose 12ml/kg
Propofol is not a suitable substitute for lipid emulsion
Without Cardio-Resp Arrest
Use conventional therapies to treat:
- Tachyarrhythmia (Lidocaine should not be used as an anti-arrhythmic therapy)
In Cardio-Resp Arrest
- CPR – using standard protocols (Continue CPR throughout treatment with lipid emulsion)
- Manage arrhythmias – using standard protocols
- Consider the use of cardiopulmonary bypass if available
- Recovery from LA-induced cardiac arrest may take >1 h
- Lidocaine should not be used as an anti-arrhythmic therapy
Recent Incident: Bat contact was not recognized (effectively touching a bat without gloves means treatment is recommended)
Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in “Rabies-Free” counties the bat population posse a risk.
In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.
Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.
To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]
Combined Country/Animal & Exposure Risk
Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.
If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)
You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]
Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400