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Drugs for the doctor's bag: 1–adults
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Abstract

In the past, GPs carried a range of medicines for acute or emergency visits, which is now less necessary where paramedics are trained and equipped, and where emergency transfers to hospital are rapid. Indeed, acute services and ambulance trusts in some areas may discourage GPs from attending emergencies as it could delay patient transfers. However, there is still a need for some GPs to carry a range of medicines for use in acute situations when on home visits. What to include in the GP's bag is determined by the medical conditions likely to be met; medicines the GP is confident and competent to use; storage requirements and shelf-lives of drugs; ambulance paramedic cover and the proximity of the nearest hospital.1 Here we suggest medicines suitable for GPs for emergency or acute treatment of adult patients, updating our previous advice and including the underlying guideline recommendations for their use.1 A later article will cover treatment for children. The intention is not to imply that every doctor should carry every drug mentioned. Instead, we aim to highlight some of the key treatments and suggest choices in some of the more common clinical scenarios that GPs may have to deal with in everyday practice, which may be prior to referral to secondary care. Each section ends with a list of drug recommendations for the doctor's bag; drugs may be referred to in several sections but are only listed in one section to avoid repetition. The article does not provide recommendations for drugs to be stocked for use in routine clinical practice in the surgery (e.g. for minor surgery) or for drugs to be held by out-of-hours primary care services. Separate guidance and advice is available on drugs suitable for use by those providing out-of-hours primary care services.2 For example, in England a national out-of-hours core formulary contains the minimum list of drugs that patients should be able to access.2

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Medicines information

Healthcare professionals should refer to the British National Formulary (BNF)3 and Summaries of Product Characteristics (SPCs) for details of indication, dosing, administration, cautions and contraindications, drug interactions and adverse effects of medications. Instructions on intravenous (i.v.), intramuscular (i.m.) and subcutaneous administration of drugs are available in the BNF and SPC. Copies of SPCs are available from the Medicines and Healthcare products Regulatory Agency's website (http://www.mhra.gov.uk/spc-pil/) and the Electronic Medicines Compendium (https://www.medicines.org.uk/emc/). Doses quoted in the article are based on the standard dose for adults. Lower doses may be required because of age, frailty, reduced renal function, impaired hepatic function, interacting drugs and comorbidities. For all injections, doctors should ensure that they have access to an appropriate diluent.

Acute pain

Guideline recommendations: mild to moderate pain

It is recommended that a step-wise approach is used for managing mild-to-moderate pain in adults.4 Paracetamol is a suitable step 1 analgesic for most patients with mild to moderate pain,4 and can be replaced by an NSAID (e.g. ibuprofen 400mg) at step 2.4 If the person is unable to take an NSAID, use a full therapeutic dose of a weak opioid (e.g. codeine 30–60mg, dihydrocodeine 30mg).4 Step 3 adds paracetamol and ibuprofen, or if the person is unable to tolerate an NSAID, adds paracetamol to a weak opioid.4

For the doctor's bag

Paracetamol 500mg tablets

Ibuprofen 400mg tablets

Codeine 30mg tablets

Guideline recommendations: severe pain

For rapid relief of severe pain (e.g. acute renal colic),5 administer a parenteral analgesic:

  • Give diclofenac 75mg intramuscularly unless contraindicated; suppositories may also be considered.

  • If diclofenac is not suitable or is insufficient to control the pain, consider an opioid; this should be given with an antiemetic.

For the doctor's bag

Diclofenac sodium 25mg/mL 3mL ampoules

Diclofenac 100mg suppositories

Diamorphine 2.5–10mg injection

Acute myocardial infarction and angina

Guideline recommendations

Patients with suspected acute coronary syndrome should be offered pain relief as soon as possible.68 This may be achieved with glyceryl trinitrate (GTN; 300–600micrograms [1–2 tablets] sublingually every 5 minutes when required, maximum 3 doses in 15 minutes; or 400–800micrograms [1–2 sprays] sublingually every 3–5 minutes when required, maximum 3 doses in 15 minutes), but consider intravenous opioid particularly if an acute myocardial infarction is suspected. If an opioid is used, this should be given with an antiemetic.

Offer people a single loading dose of aspirin 300mg orally as soon as possible, unless it is contraindicated due to allergy.7 If aspirin is given before arrival at hospital, send a written record with the person.7

For the doctor's bag

Aspirin 300mg tablets

Glyceryl trinitrate 400microgram sublingual spray (tablets are not recommended because once the bottle is opened, the tablets have to be used within 8 weeks).

Acute left ventricular failure

Guideline recommendations

The National Institute for Health and Care Excellence (NICE) guidance for the initial pharmacological treatment of acute heart failure recommends offering intravenous diuretic therapy (e.g. furosemide 40mg initially; rate not to exceed 4mg/minute).9,10 Scottish Intercollegiate Guidelines Network (SIGN) guidance recommends that nitrates should be used in acute coronary syndromes to relieve cardiac pain due to continuing myocardial ischaemia or to treat acute heart failure.11

For the doctor's bag

Furosemide 10mg/mL injection

Furosemide 40mg tablets

Anaphylaxis

Guideline recommendations

Adrenaline is the most important drug for the treatment of an anaphylactic reaction.12 For people with clinical features of anaphylaxis:1214

  • Give adrenaline 500micrograms intramuscularly 1:1,000 (0.5mL).

The intramuscular route is the best for most individuals who have to give adrenaline to treat an anaphylactic reaction. The patient should be monitored (pulse, blood pressure, ECG, pulse oximetry) as this will help assess the response to adrenaline.12

When skills and equipment are available:

  • Oxygen

  • Intravenous fluid challenge

Following initial resuscitation:

  • Chlorphenamine 10mg intramuscularly or intravenously (i.v. administration: injected slowly over a period of 1 minute, using the smallest adequate syringe to ensure sufficient control over the length of time of administration).15

  • Hydrocortisone 200mg intramuscularly or intravenously (i.v. administration: injected slowly).16

The presenting symptoms and signs of a severe anaphylactic reaction and life threatening asthma can be the same. If the patient has asthma-like features alone, follow the British Thoracic Society/SIGN asthma guidelines.12

For the doctor's bag

Adrenaline 1:1,000 injection (1mg/mL)

Adrenaline 300microgram prefilled pen injection (it is important the user has been trained in its use)

Chlorphenamine 10mg/mL injection

Hydrocortisone sodium succinate 100mg injection

Asthma

Management of acute severe asthma in adults in general practice should follow British Thoracic Society (BTS)/SIGN guidance.17

Guideline recommendations

Use high-dose inhaled beta2 agonist (e.g. salbutamol: 100microgram/dose metered-dose inhaler [MDI]) via a large volume spacer device.17 For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to a maximum of 10 puffs.17,18 Each puff should be given one at a time and inhaled with five tidal breaths. The above process may be repeated every 10–20 minutes if clinically necessary while the person is awaiting hospital admission. An alternative is to use nebulised beta2 agonist therapy, ideally driven by a high-flow oxygen-driven nebuliser if available.

In severe asthma that is poorly responsive to an initial bolus dose of beta2 agonist, consider continuous nebulisation of a beta2 agonist with an appropriate nebuliser.1720 Add nebulised ipratropium bromide (0.5mg 4–6 hourly) to beta2 agonist treatment for patients with acute severe or life-threatening asthma or those with a poor initial response to beta2 agonist therapy. SIGN/BTS and Global Initiative for Asthma (GINA) guidelines include the recommendation to give supplementary oxygen (high-flow oxygen: 40–60% with a tight-fitting mask) to all hypoxaemic patients with acute severe asthma to maintain an SpO2 level of 94–98%.1720 Lack of pulse oximetry should not prevent the use of oxygen.

BTS/SIGN guidelines recommend that adults presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation (e.g. prednisolone 40–50mg orally, hydrocortisone 100mg intravenously).17,2022

For the doctor's bag

Salbutamol 100microgram/dose MDI with large volume spacer

Prednisolone 5mg tablets

Hypoglycaemia

Guideline recommendations

For conscious patients, guidelines suggest that mild to moderate hypoglycaemia should be treated by the oral ingestion of any available glucose/sucrose-containing fluid in people who are able to swallow. Glucose-containing tablets or gels are also suitable for those able to dissolve or disperse these in the mouth and swallow the products. One guideline recommends 15g carbohydrate, preferably as glucose or sucrose tablets or solution.23 Patients should retest blood glucose in 15 minutes and re-treat with a further dose of carbohydrate if the level remains <4.0mmol/L. Severe hypoglycaemia in a conscious person should be treated by oral ingestion of 20g carbohydrate, preferably as glucose tablets or equivalent. Blood glucose should be retested in 15 minutes and then re-treated with another 15g glucose if the level remains <4.0mmol/L.23

For patients with decreased level of consciousness due to hypoglycaemia who are unable to take oral treatment safely:23,24

  • give i.m. glucagon;

  • monitor for response at 10 minutes, and then give intravenous glucose if the level of consciousness is not improving significantly;

  • then give oral carbohydrate when it is safe to administer it, with the individual placed under continued observation by a third party who has been warned of the risk of relapse.

For the doctor's bag

Proprietary quick-acting carbohydrate (e.g. GlucoGel, Dextrogel)

Glucagon 1mg injection

Glucose 20% injection 50mL (given slowly into a large vein through a large-gauge needle [this concentration is an irritant especially if extravasation occurs]).3

Hypoadrenalism

Patients on corticosteroid therapy for more than a few weeks are at risk of adrenal crisis (characterised by vomiting, hypotension and shock) if they stop their corticosteroid suddenly, particularly if they are unwell (e.g. due to intercurrent gastroenteritis); or if while on low-dose or replacement-dose corticosteroid they fail to appropriately increase their corticosteroid dose in the event of acute illness.1

Guideline recommendations

Treatment of an adrenal crisis includes giving hydrocortisone 100mg intramuscularly or by slow i.v. injection.25,26

For the doctor's bag

Hydrocortisone sodium phosphate 100mg/mL solution for injection

Suspected bacterial meningitis/meningococcal septicaemia

Guideline recommendations

For the treatment of suspected bacterial meningitis with non-blanching rash or meningococcal septicaemia, administer a single dose of benzylpenicillin 1.2g parenterally at the earliest opportunity, provided that treatment does not delay urgent transfer to hospital.27,28 Cefotaxime 1g (given intravenously or intramuscularly) is an alternative.3,28

  • Ideally, benzylpenicillin should be given by slow i.v. injection or intramuscularly if a vein is not available.

  • If administered intramuscularly, it should be given as proximally as possible—preferably into a part of the limb that is still warm (as cold areas will be less well perfused).

  • Withhold benzylpenicillin if the person has a clear history of penicillin anaphylaxis (a history of a rash following penicillin is not a contraindication).27

  • If given intravenously, cefotaxime should be injected over a period of 3–5 minutes.29

For the doctor's bag

Benzyl penicillin 600mg injection

Cefotaxime 1g injection

Nausea and vomiting

Guideline recommendations

Administer an antiemetic for nausea and vomiting (particularly if an injectable opioid is given). Metoclopramide and prochlorperazine can cause acute dystonia including oculogyric crisis, particularly in young and elderly people. This effect can be reversed by procyclidine (5mg/mL injection). Cyclizine can also be given to reduce the likelihood of opioid-induced vomiting. However, it is not recommended in patients with suspected myocardial infarction because it causes peripheral vasoconstriction and may aggravate heart failure and counteract the haemodynamic benefits of opioids. Metoclopramide can also be used to treat people with nausea and vomiting associated with opioid use.1

  • Cyclizine 50mg i.m.

  • Metoclopramide 10mg i.m. (but avoid in people younger than 20 years old).

  • Prochlorperazine 12.5mg by deep i.m. injection.5,30

For the doctor's bag

Cyclizine 50mg/mL injection

Metoclopramide 5mg/mL injection

Prochlorperazine 12.5mg/mL injection

Opioid overdose

Guideline recommendations

Naloxone 0.4–2mg given intravenously, repeated every 2–3 minutes up to a maximum of 10mg, should be used for collapse due to opioid overdose.31,32 In practice, most overdoses will respond to 400–800micrograms naloxone (i.e. 1–2 ampoules).31 Administration by the i.m. (initial dose usually 0.4–2mg) or subcutaneous route may be necessary if the i.v. route is not accessible.32 Pain control will be reversed in those taking opioids for analgesia, so pain should be reviewed and appropriately managed. The BNF highlights that doses used in acute opioid/opiate overdose may not be appropriate for the management of opioid/opiate induced respiratory depression and sedation in those receiving palliative care and in chronic opioid/opiate use.3

For the doctor's bag

Naloxone 400micrograms/mL injection

Seizures

Guideline recommendations

NICE guidelines on the management of prolonged or repeated seizures and convulsive status epilepticus33 recommend administering buccal midazolam 10mg as first-line treatment in adults in the community (off-label use), or rectal diazepam 10–20mg if preferred or if buccal midazolam is not available. If intravenous access is already established and resuscitation facilities are available, administer intravenous lorazepam (0.1mg/kg; usually a 4mg bolus, repeated once after 10–20 minutes).

SIGN guidelines on the diagnosis and management of epilepsy in adults34 include recommendations that patients with generalised tonic-clonic status epilepticus should receive oxygen and lorazepam 4mg intravenously or diazepam 10mg intravenously if lorazepam is unavailable. Intravenous lorazepam and diazepam are both effective and safe in controlling tonic-clonic status epilepticus, when administered by paramedics, prior to transport to hospital, with a trend in favour of lorazepam. This can be repeated in hospital after 10 minutes if there is no response. If there is a delay in gaining intravenous access in the community, give diazepam 10–20mg rectally.

For the doctor's bag

Diazepam rectal solution 10mg in 2.5mL

Midazolam oromucosal solution 5mg/mL

Palliative care

Access to drugs in the community is important to avoid crises at home and to reduce unwanted or unnecessary admissions in the last days of life. Schemes that provide supplies of drugs used in palliative care may be available through community pharmacies or GP surgeries. Where such schemes are not available or accessible, consideration should be given to carrying a range of drugs that are commonly used.35

Guideline recommendations

Prescribers are encouraged to prescribe sufficient quantities of medication to manage sudden changes in the patient's condition, or pro-actively prescribe injectable drugs commonly used at the end of life which are then available in the home on an ‘if needed’ basis. Drugs that are commonly recommended for palliative care include:35

  • diamorphine (injection)

  • cyclizine (injection)

  • dexamethasone (tablet)

  • hyoscine butylbromide (injection)

  • ketorolac or diclofenac (injection)

  • levomepromazine (injection)

  • midazolam (injection)

For the doctor's bag

Hyoscine butylbromide 20mg/mL injection

Midazolam 2mg/mL injection

Dexamethasone 2mg tablets

Upkeep of the bag

GP practices often maintain one or two bags for use by doctors visiting patients. The following should be considered:1

  • The bag must be lockable and not left unattended.

  • Most medicines should be stored between 4° and 25°C. A silver-coloured bag or cool bag is more likely to keep drugs cooler than a traditional black bag.

  • Consider keeping a maximum-minimum thermometer in the bag to record extremes of temperature.

  • Bright lights may inactivate some drugs (e.g. injectable prochlorperazine), so keep the bag closed when not in use.

  • It is best to store the bag in a cool place in the surgery or at home rather than in the doctor's car.

  • When it is in the car, lock the bag out of sight in the vehicle boot when not in use.

  • There should be a system in place to ensure regular review of usage and of expiry dates so that replacement stocks can be obtained before the relevant expiry date. All drugs no longer suitable for use and that have nearly expired must be disposed of safely in accordance with waste management regulations.1

Diluents to carry

A range of diluents should be carried in the doctor's bag.

For the doctor's bag

Water for injection

Sodium chloride injection 0.9%

Controlled drugs

The following apply particularly to controlled drugs (CDs):1

  • A Controlled Drug register for the CD stock held within the doctor's bag should be kept. All transactions must be recorded within 24 hours. It is suggested that the register is not kept with the bag so that in the event of theft of the bag, a record of the drugs held is not lost.

  • Restocking of the bag should be witnessed as should the appropriate entries into the CD register.

  • Safe custody requirements for CDs must be observed; the bag must be lockable and accessible only by the GP or someone authorised by them. The bag must not be stored in a car.

Information and record keeping

If oxygen is carried, the GP's car should be labelled with the correct ‘Hazchem’ sticker.1 The car insurance company should be informed.

If more than immediate treatment is given, the patient should also be given a patient information leaflet.1

The origin, batch numbers and expiry dates of all the drugs should be recorded when administered.1,36 Information on any medications given should be entered into the patient's record as soon as practicable, and this information should also go with any patient who is admitted to hospital.1

References

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