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LGI ED General Management
a. You should familiarise yourself with the policies and guidelines for drug prescriptions, such as use of analgesia, antibiotics, anti-arrthymics, anti-convulsants.
b. There are some guidelines in the Clinical Guidelines Section, especially regarding the analgesic control ladder and use of appropriate analgesia in adults and paediatrics.
· Following is the list of medication available in the department for prescribing out-of-hours. Outside prescriptions (FP10) are kept in the medicine cupboard and should only be used as a last resort when Pharmacies close out-of-hours. From Mon-Fri 9am-5pm the Accident & Emergency Pharmacist, is available for advice and to answer any queries on ext 23547. On the weekends and out-of-hours an on-call Pharmacist is available on bleep for advice.
Analgesics
- Simple Paracetamol is effective for many types of pain and should be used in the first instance. It is a safe drug for all ages, prescribed as Calpol up to the age of 6 or 7. Thereafter single Paracetamol tablets can be used. Adults should be warned against taking more than 8 x 500 mg tablets per day.
- If a stronger analgesic is required, Co-dydramol is a reasonable choice. This may be supplemented with a non-steroidal anti-inflammatory drug such as Ibuprofen 600 mg qds and the combination is often quite effective. NB. Many patients with limb trauma will experience considerable relief from their pain, simply by strict elevation of the injured part and combination analgesia.
- Patients in acute pain (dislocated major joint, long bone fracture etc) MUST be given IV morphine in a dose titrated to their pain.
- Children will often be given oral morphine (Oramorph) or intra-nasal Diamorphine. You will be guided by senior nursing staff.
Antibiotics (see also Soft Tissue Infection and the LTHT website for updates)
- For treatment of streptococcal and staphylococcal infections, Flucloxacillin 500 mg qds for 5 days is recommended. Children can be treated with Flucloxacillin elixir at the appropriate dose. In penicillin sensitivity, use erythromycin, though bear in mind that it is bacteriostatic and is not as effective in well-established infections. Oxytetracycline is a useful alternative in adults. Cephradine and other cephalosporins may be used in penicillin-sensitive patients, but bear in mind the reported 5% cross-sensitivity. Ciprofloxacin is not reliable in staphylococcal infection and should not be used without microbiological advice.
- In more serious soft tissue infection, use high dose penicillin V with high dose Flucloxacillin, together with elevation. Giving this orally for 24 hours before resorting to admission for intravenous medication is often worthwhile.
- Dog bites can be treated with oral Flucloxacillin. You must make sure to CLEAN the wound and DEBRIDE (if appropriate) as well as giving antibiotics. Seek senior help as to whether you should leave a wound open or close it for cosmesis.
- Other animal bites (e.g. cats) are usually more serious. They should be give combination antibiotics (Fluclox and Penicillin V) and followed up in the A&E Review Clinic at 2-3 days if they are significant.
- Human bites must be thoroughly cleaned and debrided. If the bite goes into the joint (classically the MCP joint following a punch) these joints need to be opened and irrigated. Human bites must receive Augmentin. Discuss with a senior.
- Do not prescribe antibiotics alone when a pus collection is present, unless it is an adjunct to surgical management in the presence of considerable cellulitis.
Conscious Sedation
- Oral sedation. Useful in paediatric cases. Midazolam is unfortunately the only drug currently available at a dose of 0.5mg/kg. Onset of action is about 20-30 minutes. Do not forget to give the parents written advice on how to manage a child after sedation. Be aware that a sub set of children become more agitated with midazolam, not less! Talk to a senior.
- Intravenous sedation. Ideal for reducing large joint dislocations and fracture manipulations. Be careful when giving intravenous opiates with benzodiazepines. You should never do this without an experienced senior doctor being present. Sedation requires 2 doctors present, a trained nurse, cardiac monitoring, an oxygen mask and a pulse oximeter.
- Entonox (N2O and O2) administration. Inhalational mixture through a demand valve. Very useful for immediate effect whilst waiting for IV morphine or as a supplemental agent for relocating certain joints (a dislocated shoulder…in combination with a good technique)
12b. Management of opiate withdrawal – dihydrocodeine dosing recommendations (based on Leeds Addiction Unit Practice).
These are only a guideline. Ask a Senior if in doubt. If your patient is an IV drug user please ask how much he spends daily on drugs. Use the following guideline as an indicator of how much dihydrocodeine to prescribe during his/her in hospital stay.
Up to £30 spent – 90-120mg QDS + 90-120mg up to BD PRN
£30 and over – 150mg QDS + 150mg up to BD PRN (can start at a lower dose and increase if appropriate).
The first dose given should be assessed for efficacy and side effects before continuing.
It is important to stress the need for monitoring prior to dosing to ensure the patient does not have symptoms of opiate toxicity (due to excess dosing or continued IVDU). Suggest using a neuro observation chart (BP, pulse, pupils size etc).
Methadone should only be prescribed if the patient is on a Detox regimen already. Before prescribing Methadone the patient’s usual dose MUST be checked with the prescriber, Community Pharmacy or a current valid prescription.
12c. Antimicrobial Prescribing Guidance – See Booklet available in the department