Clinical review of drug contraindications and allergies

CLINICAL REVIEW OF DRUG CONTRAINDICATIONS
AND ALLERGIES IN THE
understanding of the system and how best to METROPOLITAN AMBULANCE SERVICE
It is important to note that this work was The value of this clinical collection system has been identified by most other ambulance services in Australia with some already using the system and others about to sign-up for access to it. This means that in the near providing evidence of our practice, there is future most, if not all services will be using a still a significant input required from clinical common system which will enable improved and technical personnel in designing and testing the validity of various reports. John Winterton, Manager Clinical Support and Salman Sabir, our Data Retrieval Officer Meanwhile, the Paramedic Education & accomplished this work after a consistent and focussed effort over a number of weeks. They conduct an electronic review into the use of all pharmacology guidelines authorised for This report indicates that MAS paramedics perform to a high standard and that evidence This review looked at all drug administrations can be collected and reported on quickly in the light of the indicated contraindications, enabling clinical improvements to be made on as defined in the 2006 edition of the Clinical Practice Guidelines (CPGs). The period of the review was for the first six months of The work completed for this report is the beginning of an exciting era of evidenced based practice, which we have all sought for accessed during this time period. All ePCRs were electronically searched to identify the I would like to personally congratulate all MAS paramedics on their high standard of care in relation to patient care and for their Any previous work of this nature would have patience in assisting the implementation of involved a laborious and tedious process of hand searching and data entry before any analysis could take place. The use of the electronic system enabled the review to be completed quickly and accurately for prompt Introduction
I would like to congratulate all those involved successfully implemented into all MAS teams. We have been focussed on seeking feedback from paramedics to ensure the electronic acceptance of the change from written to collection of clinical information continues to be developed as a user-friendly process. The conversion from the hand-written Patient Care Record (PCR) to the electronic ePCR was a significant challenge for some and a substantial change to previous ambulance practice. However at this time it is apparent that most paramedics have a good practical understanding and use of the system. Clinical Review of Drug Contraindications and Allergies.doc Acetylsalicylic Acid – Aspirin
Over the first six months of 2007, Adrenaline The contraindications for the administration of Acetylsalicylic Acid as defined in the current Adrenaline administrations to patients presenting in
hypovolaemic shock without fluid replacement
• Hypersensitivity to aspirin / salicylates No of pts who were administered Adrenaline for hypovolaemic shock without fluid replacement Acetylsalicylic Acid was administered on compromised, peripheral vasoconstriction and tachycardia occur in the endeavour to
Aspirin administrations to patients with documented
compensate for the falling blood pressure. allergy or hypersensitivity
Adrenaline is contraindicated in this cohort of considerably vasoconstricted. Hypovolaemia No of patients who were administered Aspirin to is best managed by intravenous fluid 1. One patient initially denied he had an allergy to Aspirin. After receiving Aspirin, remembered that he had allergy, and soon developed onset of anaphylaxis. MICA attended and treated Amiodarone
The contraindications for the administration of Aspirin administrations to patients with documented pre-
existing bleeding disorder
Amiodarone as defined in the current CPG No of pts who were administered Aspirin with documented pre-existing bleeding disorders Aspirin administrations to patients with diagnosed G.I.
No of pts who were administered Aspirin with Aspirin administrations to patients with suspected aortic
aneurysm
No of pts who were administered Aspirin with Amiodarone administrations to patients with documented
One of the actions of Aspirin is that it reduces allergy or hypersensitivity
platelet aggregation that in turn affects the clotting processes. Hence it should not be No of pts administered Amiodarone where a administered to patients who are actively known allergy or hypersensitivity to the drug was bleeding or have bleeding disorders. Adrenaline Tartrate
Amiodarone administrations to pregnant patients
The contraindication for the administration of No of pts administered Amiodarone where the Adrenaline as defined in the current CPG patient was identified as being pregnant Clinical Review of Drug Contraindications and Allergies.doc Amiodarone administrations to patients in inadequately
Fentanyl Citrate administrations to patients with
perfused VT
documented allergy or hypersensitivity
Total no. of Fentanyl Citrate administrations No of pts administered Fentanyl Citrate where a conscious VT and were inadequately perfused, known allergy or hypersensitivity to the drug was where MICA crews administered Amiodarone Frusemide
There is no listed contraindication for the Amiodarone has both negative chronotropic administration of Frusemide in the current and inotropic actions. In the presence of a patient who becomes hypotensive, the effects can be significantly detrimental whilst still not Over the first six months of 2007, Frusemide guaranteeing a reversion of VT. Elective cardioversion is the preferred management in Frusemide administrations to patients with documented
allergy or hypersensitivity
Atropine Sulphate
There are no listed contraindications for the No of pts administered Frusemide where a known administration of Atropine Sulphate in the Glyceryl Trinitrate
Over the first six months of 2007, Atropine The contraindications for the administration of Glyceryl Trinitrate as defined in the current Atropine Sulphate administrations to patients with
documented allergy or hypersensitivity
• Systolic blood pressure < 110 mmHg Total no. of Atropine Sulphate administrations No of pts administered Atropine Sulphate where a • Systolic blood pressure < 90 mmHg known allergy to the drug was documented. Ceftriaxone
The contraindication for the administration of Ceftriaxone as defined in the current CPG • Allergies to Cephalosporin Antibiotics Over the first six months of 2007, Ceftriaxone • Inferior STEMI with systolic BP < 160 Ceftriaxone administrations to patients with documented
allergy or hypersensitivity
Over the first six months of 2007, GTN was Total no. of Ceftriaxone administrations administered on 10,840 occasions. Of the No of pts administered Ceftriaxone where a 10,840 administrations recorded, GTN was known allergy to the drug was documented. delivered by means of 0.4 mg/hr patch on 2900 occasions, and by means of tablet on Fentanyl Citrate
The contraindications for the administration of Fentanyl Citrate as defined in the current Over the first six months of 2007, Fentanyl Citrate was administered on 327 occasions. Clinical Review of Drug Contraindications and Allergies.doc GTN Tablet Administration
GTN Patch Application
GTN tablet administrations with documented allergy or
GTN patch applications with documented allergy or
hypersensitivity
hypersensitivity
GTN tablet administrations with documented systolic
GTN patch applications with documented systolic blood
blood pressure of <110/P
pressure of <90/P
No of pts with documented systolic blood No of pts with documented systolic blood pressure of <110/P immediately prior to pressure of <90/P immediately prior to application GTN patch applications with documented bradycardia
GTN tablet administrations with documented bradycardia
immediately prior to GTN tablet administration 5. Of the 68 administrations, 17 were administered to patients 3. Of the 254 administrations, 41 were administered to patients
GTN patch applications with documented heart rates 150>
GTN tablet administrations with documented heart rates
150> min
No of pts with documented Heart Rates 150> No of pts with documented Heart Rates 150> GTN patch applications with documented ST elevation in
GTN tablet administrations with documented ST elevation
inferior leads/Inferior infarction with BP <160/P
in inferior leads/Inferior infarction with BP <160/P
No of pts with applied GTN patches following No of pts with administered GTN tablets following documented ST elevation in inferior leads/inferior documented ST elevation in inferior leads/inferior 4. One pt’s BP dropped to 70/S post administration and GTN patch applications whilst in Ventricular Tachycardia
Total no. of GTN patches administrations Two patients suffered VF arrests some 6 minutes post No of pts given GTN patches when the patient administration and were successfully cardioverted. It is difficult to determine if the administration of GTN in these patients was a contributing factor to the cardiac arrest or GTN patch applications to patients medicated with Viagra,
Levitra or Cailis where
GTN tablet administrations whilst in Ventricular
Tachycardia
Total no. of GTN patches administrations No of pts given GTN patches who have taken Sildenafil Citrate “VIAGRA” or Vardenafil No of pts administered GTN tablets when the “LEVITRA” within the previous 24 hours or Tadalafil “CAILIS” within the previous 4 days GTN tablet administrations to patients medicated with
Viagra, Levitra or Cailis where
Due to the hypotensive side effect of GTN, it No of pts administered GTN tablets who have is not to be administered to patients with taken Sildenafil Citrate “VIAGRA” or Vardenafil tachycardia/VT over the rate of 150/min as “LEVITRA” within the previous 24 hours or the heart is usually unable to compensate Tadalafil “CAILIS” within the previous 4 days any faster. There is a higher risk of blood pressure collapse in this cohort of patients. GTN should also not be administered to patients who have indications of an inferior infarct (ST elevation in lead II and/or III,) with an associated BP of less than 160/S as it potentially increases the incidence of right Clinical Review of Drug Contraindications and Allergies.doc GTN should also not be administered to Over the first six months of 2007, Lignocaine patients in bradycardia, as one of the Hydrochloride was administered on only 2 infarction/ischaemia can be the presence of Lignocaine Hydrochloride administrations to patients with
documented allergy or hypersensitivity
Hydrocortisone Sodium Succinate
The contraindication for the administration of No of pts administered Lignocaine Hydrochloride where a known allergy or hypersensitivity to the Hydrocortisone Sodium Succinate as defined Metaraminol Bitartrate
There is no listed contraindication for the administration of Metaraminol Bitartrate in the However, over the first six months of 2007, Metaraminol Bitartrate was administered on Hydrocortisone Sodium Succinate administrations to
patients with documented allergy or hypersensitivity
Metaraminol Bitartrate administrations to patients with
Total no. of Hydrocortisone Sodium Succinate documented allergy or hypersensitivity
No of pts administered Hydrocortisone Sodium Succinate where a known allergy to the drug was administrations No of pts administered Metaraminol Bitartrate Ipratropium Bromide
The contraindication for the administration of Methoxyflurane
Ipratropium Bromide as defined in the current The contraindications for the administration of Methoxyflurane as defined in the current CPG • Known hypersensitivity to Atropine or • Pre-existing renal disease/impairment Over the first six months of 2007, Ipratropium • Exceeding total dose of 6 ml in a 24 Ipratropium Bromide administrations to patients with
documented allergy or hypersensitivity

Total no. of Ipratropium Bromide administrations Methoxyflurane was administered on 17,692 No. of pts administered Ipratropium Bromide hypersensitivity to Atropine or its derivatives was Patients given more than 6 mls of Methoxyflurane over a
24 hour period
Lignocaine Hydrochloride
Total no. of Methoxyflurane administrations No of pts administered more than 6 mls of Lignocaine Hydrochloride is a drug that has ventricular arrhythmias. The contraindication Methoxyflurane administrations to patients with
documented renal failure

Hydrochloride as defined in the current CPG Total no. of Methoxyflurane administrations Clinical Review of Drug Contraindications and Allergies.doc Methoxyflurane administrations to patients with
of blood in the gut. This reduces the documented current use of tetracycline antibiotics

tamponade effect, resulting in the potential for Total no. of Methoxyflurane administrations No of pts with documented current tetracycline experienced following the administration of metoclopramide. The incidence of these se side effects occurring (especially dystonic reactions), are greater in children than in Methoxyflurane potentially has nephrotoxic adults; hence its use is contraindicated in effects and accordingly is not to be diagnosed renal failure/impairment. Midazolam
The concurrent use of tetracycline and The contraindication for the administration of Methoxyflurane has been reported to result in Midazolam defined in the current CPG book Metoclopramide
The contraindications for the administration of Metoclopramide as defined in the current Over the first six months of 2007, Midazolam Midazolam administrations to patients with documented
allergy or hypersensitivity to benzodiazepines
No of pts with documented allergy administered Metoclopramide was administered on 3,608 Morphine Sulphate
The contraindications for the administration of Metochlopramide administrations to patients with
Morphine Sulphate as defined in the current documented pre-existing or suspected bowel obstruction,
perforation or gastrointestinal bleed

Total no. of Metoclopramide administrations No of pts with documented pre-existing or suspected bowel obstruction or perforation or Over the first six months of 2007, Morphine Metochlopramide administrations to patients who were
aged under 15 years

Morphine Sulphate adminstrations to patients in late
Total no. of Metoclopramide administrations second stage of labour
No of pts with documented administration of Metoclopramide who were aged under 15 years Total no. of Morphine Sulphate administrations Five of the six patients were given Metoclopramide following No of pts in late second stage of labour who were consultation with the receiving hospital. Metoclopramide accelerates peristalsis and Morphine Sulphate administrations to patients with
gastric emptying. If administered to a patient documented allergy or hypersensitivity

with bowel obstruction, the intestinal content Total no. of Morphine Sulphate administrations will be forced at a faster rate to the point of obstruction, thus exacerbating the condition. hypersensitivity administered Morphine Sulphate 7. Of the 26 cases, the majority of indicated allergies was Metoclopramide will accelerate the passage previously asking pt of allergies prior. Clinical Review of Drug Contraindications and Allergies.doc Prochlorperazine
One pt had a significant hypotensive episode post Morphine administration (2.5mg) despite being previously advised that The contraindications for the administration of Prochlorperazine as defined in the current One pt received Morphine following consultation. Naloxone Hydrochloride
There is no listed contraindication for the administration of Naloxone Hydrochloride in Over the first six months of 2007, Naloxone Prochlorperazine was administered on 130 Prochlorperazine
administrations
patients
documented allergy or hypersensitivity
Naloxone Hydrochloride administrations to patients with
documented allergy or hypersensitivity
Total no. of Prochlorperazine administrations No of pts with documented allergy administered No of pts administered Naloxone Hydrochloride Prochlorperazine administrations to patients with
documented circulatory collapse
Total no. of Prochlorperazine administrations Pancuronium Bromide
No of pts with documented circulatory collapse The contraindications for the administration of Prochlorperazine
administrations
patients
documented CNS depression
Total no. of Prochlorperazine administrations No of pts with documented CNS depression Prochlorperazine administrations to patients who were
aged under 15 years
Total no. of Prochlorperazine administrations No of pts with documented CNS depression Prochlorperazine can cause very serious acute dystonic reactions in children leading to Pancuronium Bromide administrations to patients with
documented allergy or hypersensitivity
requiring artificial ventilation, life-threatening tetanus-like syndromes, coma and even death. These reactions can occur with a No of pts administered Pancuronium Bromide It is also proven to have other CNS effects Pancuronium Bromide administrations to patients with no
including seizures, headache, insomnia, documented use of pulse oximetry/capnography
catatonia, and hyperpyrexia. If the patient already presents with CNS depression, any No of pts administered Pancuronium Bromide where the use of pulse oximetry only was not No of pts administered Pancuronium Bromide Likewise, if the patient is presenting with where the use of neither pulse oximetry nor circulatory collapse, the potential hypotensive 8. All 8 cases were post cardiac arrested patients. and cardiac side effects of the drug may severely compromise the patient even further. Clinical Review of Drug Contraindications and Allergies.doc Salbutamol
There is no listed contraindication for the Suxamethonium can cause can cause an administration of Salbutamol in the current Over the first six months of 2007, Salbutamol If the patient is paralysed and intubation Salbutamol administrations to patients with documented
allergy or hypersensitivity
patient’s respiratory drive is negated and ventilation may then be compromised No of pts administered Salbutamol where a particularly if the patient has increased known allergy to the drug was documented.
Suxamethonium Chloride
Verapamil Hydrochloride
The contraindications for the administration of Suxamethonium Chloride as defined in the The contraindications for the administration of Verapamil Hydrochloride as defined in the Over the first six months of 2007, Verapamil Verapamil Hydrochloride administrations
administrations No of pts administered Verapamil Hydrochloride on 142 occasions. Of the 142 administrations where a known allergy or contraindication to the recorded, Suxamethonium Chloride was not On reviewing drug administration over the first 6 months of 2007, there were 56,983 occasions where drugs10 were administered allergic to the drug or contraindicated for its use. This reflects in an overall compliance Suxamethonium administrations to patients with
documented severe respiratory distress
These figures exclude the administration of Total no. of Suxamethonium administrations No of pts with documented respiratory rates of 30 No of pts with documented respiratory rates of 40 or higher/min to whom crews administered 9. These cases may have elevated respiratory rates due to a variety of factors including pain response, hypovolaemia or hypoxia. Not all are necessarily contraindicated. Clinical Review of Drug Contraindications and Allergies.doc • There was very limited use of a drug It is interesting to note that the review has highlighted an issue regarding the use of Glyceryl Trinitrate where paramedics noted defined contraindications, GTN administration The findings of this work concerning the presence of a stated contraindication will be further investigated over the next few months. It is reasonable to say that while some of the GTN Contraindications were changed in 2006 and these changes were based upon the best available information, many paramedics have expressed concern that some of the changes in the GTN contraindications were excessive. The evaluation of the use of GTN, where there are recorded Contraindications, will determine if there has been any harm observed in these variations or there is a question around the applicability of some of the contraindications. The result of this next piece of work will be useful feedback to the CPG Working Group and Clinical Review of Drug Contraindications and Allergies.doc

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