PROSEDUR OPERASI STANDARD (SOP)
1 PROSEDUR OPERASI STANDARD (SOP) PENGURUSAN UBAT BAGI PENGOPERASIAN PERKHIDMATAN AMBULANS LEMBAH KLANG (KVAS)
P A G E 1 3 2 SOP DISEDIAKAN OLEH JABATAN KESIHATAN NEGERI SELANGOR JABATAN KESIHATAN WILAYAH PERSEKUTUAN &PUTRAJAYA HOSPITAL KUALA LUMPUR Pn. Rozian Binti Abu Chik Pn. Norharlina Binti Sulaiman Pn. Teh Chew Charn Pn. Nurul Husna Binti Sodri Pn. Farrah Idayu binti Zakaria En. Saifullah Al-Mujahidi Bin Mohamad Uda Pn. Nor Aziah Binti Abdullah Pn. Teng Sook Yee Pn. Hor Yee Yee Pn. Noraini Binti Mohamad Dr.Hadijah Binti Mohd Taib Pn. Natasha Binti Mohd Dani Goh GLOSARI AKRONIM KVAS - Klang Valley Ambulance Service PTJ - Pusat tanggungjawab PRPA - Perkhidmatan Rawatan Pra Hospital dan Ambulans SOP - Prosedur Operasi Standard
3 ISI KANDUNGAN SOP DISEDIAKAN OLEH…………………………………………………………………………………………………… 2 GLOSARI AKRONIM………………………………………………………………………………………………………… 2 1. PENGENALAN…………………………………………………………………………………………………………… 4 2. OBJEKTIF………………………………………………………………………………………………………………….. 4 3. SENARAI UBAT STANDARD – JADUAL 1…………………………………………………………………….. 5 4. MEDICAL DIRECTION………………………………………………………………………………………………… 6 5. ARAHAN AM PEMBERIAN UBATAN………………………………………………………………………….. 7 6. PROSEDUR……………………………………………………………………………………………………………….. 8 7. KAEDAH PERTUKARAN UBAT-UBATAN DI HOSPITAL YANG MENERIMA KES – JADUAL 2…………………………………………………………………………………………………………………. 10 8. CARTA ALIRAN KERJA KAEDAH PERTUKARAN UBAT-UBATAN DI HOSPITAL YANG MENERIMA KES………………………………………………………………………………………………………… 11 9. SENARAI RUJUKAN…………………………………………………………………………………………….….…. 12 LAMPIRAN 1: PROTOKOL UBAT UNTUK RAWATAN PESAKIT DI DALAM AMBULANS KVAS…. 13 LAMPIRAN 2: SENARAI SEMAK HARIAN PASUKAN PERKHIDMATAN AMBULANS LEMBAH KLANG………………………………………………………………………………………………………………………………. 44
P A G E 1 3 4 1. PENGENALAN Projek Rintis Perkhidmatan Ambulans Lembah Klang atau Klang Valley Ambulance Service (KVAS) melibatkan perkhidmatan ambulans di kawasan terpilih di Selangor dan Wilayah Persekutuan Kuala Lumpur dan Putrajaya. Tujuan projek rintis ini adalah untuk meningkatkan keupayaan respon perkhidmatan ambulans di kawasan penduduk padat dan penyeragaman semua aktiviti klinikal petugas pra hospital. Susulan daripada itu, SOP Pengurusan Ubat Bagi Pengoperasian Perkhidmatan Ambulans Lembah Klang ini diwujudkan bagi memperincikan prosedur serta tatacara pengendalian ubat-ubatan termasuk bahan psikotropik di dalam ambulans. SOP ini hanya terpakai untuk perkhidmatan ambulans yang terlibat dengan KVAS sahaja. 2. OBJEKTIF 2.1.Menetapkan dan menyeragamkan tatacara atau sistem pengurusan ubat berkaitan penyimpanan, pengeluaran, administrasi, pelaporan dan pengisian semula ubat-ubatan dalam memastikan penggunaan ubat adalah terkawal dan menepati garis panduan dan akta yang berkaitan. 2.2.Mewujudkan satu beg simpanan ubat (atau yang setara) oleh fasiliti kesihatan bagi kegunaan di dalam ambulans. Jenis beg simpanan ubat (atau yang setara) adalah tertakluk kepada PTJ masing-masing dan perlu mempunyai ciri-ciri asas seperti berikut: a. Mudah dibersihkan b. Kalis air c. Dapat melindungi ubat dalam bentuk ampul/vial daripada pecah dan keadaan suhu/cahaya melampau d. Mempunyai ruang berasingan yang bersesuaian untuk mengasingkan vial yang belum digunakan dan yang telah digunakan (bagi pengasingan ampul kosong bahan psikotropik). 2.3.Menyenaraikan ubat standard dengan had kuantiti di dalam beg (atau yang setara) ubat kecemasan beserta butiran khusus (Rujuk Jadual 1).
P A G E 1 3 5 3. SENARAI UBAT STANDARD – JADUAL 1 BIL JENIS UBAT STOK MEDICAL DIRECTION 1 Diclofenac 75mg/3ml Injection (A/KK) 3 ampul √ 2 Tramadol 50mg/ml Injection (A) 2 ampul √ 3 Morphine 10mg/ml Injection (B) 1 ampul √ 4 Fentanyl 50mcg/ml Injection (A) 1 ampul √ 5 Ketamine 10mg/ml Injection (B) 1 ampul √ 6 Midazolam 5mg/ml Injection (A) 2 ampul √ 7 Adrenaline 1mg/ml Injection (1:1000) (B) 10 ampul √ 8 Atropine 1mg/ml Injection (B) 3 ampul √ 9 Tranexamic Acid 500mg/5ml Injection (B) 6 ampul √ 10 Metoclopramide 10mg Injection (B) 2 ampul √ 11 Hydrocortisone 100mg Injection (C) 2 ampul √ 12 Haloperidol 5mg/ml Injection (B) 1 ampul √ 13 Chlorpheniramine Maleate 10mg/ml Injection (B) 2 ampul √ 14 Magnesium Sulphate 2.47g/5ml Injection (C) 4 vial √ 15 Naloxone HCL 0.4mg/ml Injection (B) 3 vial √ 16 Flumazenil 0.1mg/ml Injection (B) 3 vial √ 17 Diazepam 10mg/2ml Injection (B) 1 ampul √ 18 Diazepam Rectal Solution 5mg (B) 1 tube √ 19 Salbutamol Nebuliser Solution (0.5% W/V) 1 botol √ 20 Combivent Nebuliser Solution (B) 6 ampul √ 21 Dextrose 20% Injection in 500mls (B) 1 botol √ 22 Dextrose 10% Injection in 500mls (B) 2 botol √ 23 Normal Saline solution in 500mls 3 botol √ 24 Normal Saline solution in 100mls 3 botol √ 25 Aspirin 300mg Tablet (C) 1 strip √ 26 Clopidogrel 75mg Tablet (A/KK) 2 strip √ 27 GTN 0.5mg Tab (C) 1 botol √ 28 Dextrose 50% Injection in 10mls (B) 5 vial √ 29 Water for Injection (C+) 5 vial √ 30 Lignocaine 2% Jelly (B) 1 unit √
P A G E 1 3 6 4. MEDICAL DIRECTION 4.1.Medical Direction adalah arahan yang diperolehi daripada Pakar Perubatan yang bertugas atas panggilan (oncall) bagi pengunaan ubat-ubatan di dalam ambulans. Arahan tersebut meliputi perkara berikut: - a. Konsultasi secara lisan melalui telefon atau/dan seumpamanya dan disusuli dengan mendokumenkan ke dalam dokumen pesakit contoh: Borang Laporan Pesakit Perkhidmatan Ambulans Kecemasan sebagai bukti penggunaan ubat. b. Bagi ubat psikotropik, ianya perlu disusuli dengan preskripsi (ditandatangan timbal oleh Pakar Perubatan mengikut prescribing category ubat). Sebagai yang dinyatakan dalam Peraturan 11(6) Peraturan-Peraturan Racun (Bahan-Bahan Psikotropik) 1989, pembekalan bahan psikotropik boleh dilakukan secara lisan melalui telefon daripada preskriber. Walaubagaimanapun, pembekalan hanya untuk 1 hari dan preskripsi diperlukan dalam tempoh 1 hari (24 jam) daripada tarikh pembekalan. c. Butiran pesakit yang menggunakan ubat psikotropik perlu direkodkan di dalam Buku Daftar Psikotropik fasiliti kesihatan yang menerima kes. 4.2.SEMUA ubat adalah DIWAJIBKAN untuk mendapatkan medical direction sebelum sebarang pemberian ubatan dalam Jadual 1 dibuat (bagi tujuan keselamatan pengubatan dan ketepatan dos).
P A G E 1 3 7 5. ARAHAN AM PEMBERIAN UBATAN 5.1.Senarai nama anggota bertugas KVAS perlu disediakan dan dikemaskini dari masa ke semasa bagi memastikan kawalan dan keselamatan penggunaan adalah terjamin. Sekiranya anggota didapati tidak mematuhi SOP ini atau mana-mana garis panduan dan akta yang berkaitan, anggota tersebut akan ditarik kelayakannya (atau atas sebab lain yang munasabah) dan nama anggota tersebut perlu digugurkan. 5.2.Responder KKM tertakluk kepada protokol perawatan (Rujuk Lampiran 1) berpandukan Medical Direction yang telah diperolehi. 5.3.Setiap ubat yang digunakan haruslah jelas dalam protokol perawatan mengenai: a. Indikasi – jenis situasi klinikal ia boleh digunakan. b. Kontraindikasi– jenis situasi ia tidak boleh digunakan. c. Dos d. Kesan sampingan utama yang perlu dipantau. 5.4.Kepatuhan kepada prinsip 7R dalam pemberian ubat diutamakan a. Setiap ubat hendaklah disahkan namanya oleh sekurang-kurangnya dua orang petugas. Seorang membaca label dan seorang lagi mengesahkan ia benar. b. Sebelum ubat diberikan, petugas hendaklah memaklumkan dengan jelas kepada ahli kumpulan lain, sebagai contoh menggunakan skrip berikut “saya akan memberikan (nama ubat) kepada (nama pesakit) (dos ubat) secara (administration route)”.
P A G E 1 3 8 6. PROSEDUR 6.1.UMUM a. Beg simpanan ubat (atau yang setara) hendaklah dilabelkan; contoh “BEG UBATAN KVAS”. b. Rekod membawa keluar beg simpanan ubat (atau yang setara) hendaklah disahkan oleh Penyelia Syif atau wakil dan ianya perlu didaftar masuk dan keluar pada buku khas yang dilabel, sebagai contoh; “BUKU REKOD PERGERAKAN BEG UBATAN KVAS” c. Ubat-ubatan yang ada di dalam setiap beg simpanan ubat (atau yang setara) hendaklah jelas berlabel bersama kuantiti yang dibenarkan. d. Beg yang menyimpan ubat-ubatan perlu disimpan di lokasi yang selamat bersesuaian dengan suhu dan kaedah penyimpanan. 6.2.KHUSUS a. PEMBEKALAN PERTAMA UBAT-UBATAN Pembekalan pertama ubat-ubatan ke dalam beg simpanan ubat (atau yang setara) hendaklah dibuat oleh fasiliti kesihatan KKM di mana ambulans itu ditempatkan (depot ambulans). Sekiranya ubat-ubatan yang tersenarai tiada dalam simpanan fasiliti kesihatan tersebut, stok ubat yang diperlukan boleh dimohon dari fasiliti kesihatan berdekatan yang menyimpan ubat-ubatan yang diperlukan namun perlu mengikut prosedur pembekalan fasiliti yang dipohon. b. PENGISIAN SEMULA UBAT-UBATAN Proses menokok tambah atau pengisian semula ubat-ubatan yang telah digunakan sewaktu didalam ambulans hendaklah dibuat di fasiliti kesihatan KKM yang menerima kes. (Rujuk Jadual 2) Sekiranya kes diterima oleh fasiliti kesihatan bukan KKM, pengisian semula hendaklah dibuat oleh fasiliti kesihatan KKM yang merujuk kes atau yang berdekatan. c. PERMULAAN SYIF/ ONCALL Responder bertanggungjawab ke atas pemeriksaan ubat-ubatan masing-masing. Senarai Semak Ubatan KVAS (Rujuk Lampiran 2) perlulah disemak dari segi kuantiti, tarikh luput dan dilengkapkan semasa serahan tugas dibuat. Ubat-ubatan yang tamat tarikh luputnya atau akan luput kurang dari 6 bulan hendaklah ditukar ganti kepada yang baru mengikut prosedur PTJ masing-masing. Sebarang kehilangan ubat hendaklah dilaporkan kepada Penyelia Syif untuk tindakan. Setiap fasiliti dikehendaki mengadakan pemeriksaan stok ubat-ubatan secara berkala bersama pihak farmasi PTJ (kekerapan pemeriksaan adalah bergantung kepada kesesuaian di peringkat PTJ)
P A G E 1 3 9 d. SEMASA SYIF/ ONCALL Responder bertanggungjawab ke atas keselamatan beg simpanan (atau yang setara) dan ubat- ubatan dari kerosakan fizikal, kehilangan atau kecurian dan elemen persekitaran seperti suhu. Setiap ubat psikotropik yang digunakan hendaklah mempunyai dokumen yang membuktikan penggunaannya. Bahan psikotropik adalah dikawal di bawah Peraturan-Peraturan Racun (Bahan-Bahan Psikotropik) 1989. Sehubungan dengan itu, pengendalian ubatan dari kumpulan bahan psikotropik memerlukan perekodan yang terperinci merujuk kepada Peraturan 19 dan Peraturan 22, akta berkenaan. Ini merangkumi keperluan merekod semua proses pengendalian bahan psikotropik termasuk proses pembekalan, penggunaan, pelupusan dan ketidakpatuhan oleh unit pengguna. Ubat-ubatan bukan ubat psikotropik yang tidak memerlukan preskripsi, rekod rawatan kecemasan atau dokumen bertulis yang setara juga hendaklah jelas menunjukkan nama pesakit, nombor ID/call card pesakit, nama ubat, dos ubat, kaedah pemberian, tarikh pemberian, masa pemberian, diagnosis dan nama doktor yang mengarahkan pemberian jika Online Medical Direction diperolehi. e. SELEPAS SYIF/ ONCALL Responder bertanggungjawab ke atas penyerahan semula beg ubatan Rekod masuk semula beg ubatan (atau yang setara) hendaklah disahkan oleh Penyelia Syif atau wakil (perlu daftar masuk pada buku khas yang dilabel, sebagai contoh; “BUKU REKOD PERGERAKAN BEG UBATAN KVAS” Ubatan hendaklah diperiksa dahulu kuantitinya seperti SENARAI SEMAK UBATAN KVAS (Rujuk Lampiran 2). Kehilangan / kerosakan ubat hendaklah dilaporkan kepada Penyelia Syif untuk tindakan selanjutnya.
P A G E 1 3 10 7. KAEDAH PERTUKARAN UBAT-UBATAN DI HOSPITAL YANG MENERIMA KES – JADUAL 2 BIL PERKARA TANGGUNG JAWAB CATATAN 1. Semak baki stok ubat di dalam ambulans sama ada perlu pengisian semula atau tidak. Penolong Pegawai Perubatan (PPP) Ambulans Rujuk Lampiran 2: Senarai Semak Ubatan KVAS 2. Pengisian semula ubat - bekalkan ubat mengikut kuantiti yang diperlukan Jururawat terlatih / Penolong Pegawai Perubatan (PPP) hospital yang menerima kes 1) Jika ubat Psikotropik - catatkan maklumat penggunaan dalam Buku Daftar DD/ Psikotropik (atau yang setara bagi hospital bukan KKM) - Ampul kosong bagi ubat psikotropik sahaja ditukar ganti dengan ampul baharu. 3. Hospital yang menerima kes perlu memastikan stok ubat yang sedia ada mencukupi selepas pengisian semula ubat ambulans Jururawat terlatih / Penolong Pegawai Perubatan (PPP) hospital yang dirujuk
P A G E 1 3 11 Tidak Perlu pengisian semula ubat Tamat Bekal ubat mengikut kuantiti yang diperlukan Catatkan maklumat penggunaan dalam Buku Rekod Penggunaan DD/Psikotropik (Buku Kuning) Terima ampul kosong dan dokumen (contohnya Borang laporan pesakit perkhidmatan ambulans kecemasan) daripadaPPP bertugas di ambulans Ubat psikotropik (preskripsi dalam tempoh 24 jam) Ubat bukan psikotropik 8. CARTA ALIRAN KERJA KAEDAH PERTUKARAN UBAT-UBATAN DI HOSPITAL YANG MENERIMA KES PROSES KERJA TANGGUNGJAWAB Penolong Pegawai Perubatan (PPP) Ambulans Penolong Pegawai Perubatan (PPP) Ambulans Jururawat terlatih/ Penolong Pegawai Perubatan (PPP) di fasiliti yang menerima kes Jururawat terlatih/ Penolong Pegawai Perubatan (PPP) di fasiliti yang menerima kes Jururawat terlatih/ Penolong Pegawai Perubatan (PPP) di fasiliti yang menerima kes Nota: Jabatan Kecemasan dan Trauma hospital yang menerima kes perlu memastikan stok ubat yang sedia ada mencukupi selepas pengisian semula ubat ambulans Mula Semak baki stok ubat dalam ambulans
12 9. SENARAI RUJUKAN a. Formulari Ubat KKM (FUKKM). https://www.pharmacy.gov.my/v2/en/apps/fukkm b. MIMS Gateway. https://online1.mimsgateway.com.my/ c. Peraturan-peraturan Racun (Bahan-bahan Psikotropik) 1989 d. Standard Operating Procedure (SOP) Penyeragaman Ubat Psikotropik Dan Ubat-Ubatan Lain Untuk Kegunaan Ambulans Dalam Perkhidmatan Rawatan Pra Hospital Dan Ambulans (PRPA) Di Negeri Selangor Bagi Tahun 2022
P A G E 3 13 LAMPIRAN 1 PROTOKOL UBAT UNTUK RAWATAN PESAKIT DI DALAM AMBULANS KVAS 1. MIDAZOLAM 5MG/ML GROUP Benzodiazepine derivatives. ACTION Midazolam binds to stereospecific benzodiazepine receptors on the postsynaptic GABA neuron at various sites within the CNS, including limbic system and reticular formation. Enhancement of the inhibitory effect of GABA on neuronal excitability results by increased neuronal membrane permeability to Cl ions, which results in hyperpolarisation and stabilisation. INDICATIONS Formula Ubat KKM (FUKKM) Pre-operative sedation, induction of general anaesthesia, premedication and sedation in ICU and sedation for minor procedures CONTRAINDICATIONS Hypersensitivity to midazolam or other benzodiazepines. Myasthenia gravis; acute narrow-angle glaucoma. Acute alcohol intoxication, hypnotics, neuroleptics, antidepressants or lithium. PRECAUTIONS Anaphylaxis & angioedema. Avoid intraarterial inj. Severe resp depression & arrest. Complex sleep-related behaviors; poor general condition, obese, obstructive airways diseases, sleep apnoea syndrome, cardiac decompensation; schizophrenia or endogene depression; cerebral hypoxia or paradoxical reactions; epilepsy. Dependence & tolerance. Avoid abrupt w/drawal. Longterm use. Not to be taken w/ alcohol prior to & at least 12 hr after inj. Concomitant use w/ CYP3A4 inhibitors eg, azole antifungals, macrolides. May affect ability to drive or use machines. Chronic renal or hepatic failure. Not to be used during last 6 mth of pregnancy. Lactation. Paed patients w/ CV instability; childn & adolescents <18 yr (IV). Paed <6 mth; neonates & infants up to 4-6 mth. Elderly >60 yr or debilitated patients. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) Usual sedative range 2.5 - 7.5 mg (about 70 mcg/kg by IV injection over 30 seconds). Premedication by IM injection 70 - 100 mcg/kg 30 -60 minutes before surgery; ELDERLY: 1 - 1.5 mg/kg. Induction: Induction by slow IV infusion 200 - 300 mcg/kg (ELDERLY 100 - 200 mcg/kg. CHILD over 7 years 150 - 200 mcg/kg); Maximum: 0.35mg/kg. Sedation in ICU 0.03 - 0.2 mg/kg/hour PRPA 0.2mg/kg to a maximum of 5mg Route: IM
P A G E 3 14 ADVERSE EFFECTS Vital function changes; respiratory depression & arrest, apnoea, cardiac arrest; BP, heart rate or CV parameter changes. Hiccoughs, nausea, vomiting, dry cough, marked sedation, headache, dizziness, sensitivity, erythema, injection site induration. SPECIAL NOTES Antidote Flumazenil: 0.2 mg IV over 15 seconds; if desired level of consciousness is not obtained after waiting 45 seconds, a second dose of 0.2 mg IV may be given and repeated at 60- seconds intervals as needed (up to a maximum of 4 additional times) to a maximum total dose of 1 mg; most patients respond to doses of 0.6 to 1 mg; in the event of resedation, repeated doses may be given at 20-minutes intervals if needed; for repeat treatment, no more than 1 mg (given as 0.5 mg/minute) should be given at any one time and no more than 3 mg should be given in any one hour
P A G E 3 15 2. TRAMADOL 50MG/ ML GROUP A centrally acting analgesic that has opioid agonist properties ACTION It binds to μ-opiate receptors in the CNS resulting in inhibition of ascending pain pathways, thus altering the perception of and response to pain. Its inhibition of neuronal uptake of norepinephrine and enhancement of serotonin release may also contribute to its analgesic effect. INDICATIONS Formula Ubat KKM (FUKKM) Moderate to severe acute or chronic pain (eg. Post-operative pain, chronic cancer pain and analgesia/pain relief for patients with impaired renal function) PRPA To treat moderate to severe pain. Pain score over 5 CONTRAINDICATIONS Hypotensive Acute intoxication w/alcohol, hypnotics, analgesics, opioids or psychotropic drugs. PRECAUTIONS Myasthenia gravis, head injury, increased intracranial pressure, shock, resp disorders, impaired consciousness, w/drawal syndrome. May impair ability to drive or operate machinery. Renal & hepatic impairment. Pregnancy & lactation. Children <12 yr. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) ADULT: IV/IM/SC 50 - 100mg. (IV inj over 2-3 min or IV infusion). Initially 100 mg then 50 - 100 mg every 4 - 6 hours. Max: 400 mg daily. CHILD (1 year and above): 1 - 2mg/kg/dose PRPA IV route or IM Dosage: 2mg/kg (titration of 50mg for adults) May repeat to achieve reduction in pain score by 2 Maximum offline dosage: 50mg (adults) ADVERSE EFFECTS Sweating, dizziness, nausea, vomiting, dry mouth, fatigue SPECIAL NOTES Consider Metoclopramide 10mg prior to administration of tramadol. To inform Online Medical Direction to MECC prior to administration.
P A G E 3 16 3. TRANEXAMIC ACID 500MG/5ML GROUP Hemostatic agent. Synthetic derivative of amino acid lysine ACTION Inhibits the breakdown of fibrin clots. It blocks the lysine binding sites of plasminogen and impairs the endogenous fibrinolytic process, thus preserving and stabilising the fibrin matrix structure. Additionally, it reduces inflammation associated with hereditary angioedema by inhibiting the proteolytic activity of plasmin which decreases the activation of complement and consumption of C1 esterase inhibitor (C1-INH). INDICATIONS Formula Ubat KKM (FUKKM) Haemorrhage associated with excessive fibrinolysis PRPA Non-compressible haemorrhage (internal haemorrhage); or Compressible haemorrhage that continues to bleed despite properly applied compression bandage; or Suspected intracranial haemorrhage (GCS 13 and below); or Signs of circulation compromise such as SBP <100mmHg, or PR >110 bpm CONTRAINDICATIONS History or risk of thrombosis, acquired disturbances of colour vision. PRECAUTIONS Patients w/ thrombosis or consumption coagulopathy. Elderly. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) ADULT: Slow IV 0.5-1 g (10 - 15 mg/kg) 3 times daily. Continuous infusion at a rate of 25 - 50 mg/kg daily. CHILD: slow IV 10 mg/kg/day 2-3 times daily PRPA Intravenous Injection (slow bolus) over 5-10minutes (rate 1ml/min) JKNS dilution guideline Dosage bolus: 1g or 15mg/kg in children ADVERSE EFFECTS Anorexia, hypnosia, pruritus, erythema, rash, GI disturbances, disturbances in colour vision (discontinue). SPECIAL NOTES Supply: 100mg/ml injection
P A G E 3 17 4. COMBIVENT 2.5ML/vial (COMBINATION IPRATROPIUM BROMIDE 500MCG + SALBUTAMOL 2500 MCG) GROUP A nonselective competitive antimuscarinic agent. ACTION Blocking the action of acetylcholine-induced stimulation of guanyl cyclase, hence reducing formation of cyclic guanosine monophosphate (cGMP) at parasympathetic site and causes bronchodilation. INDICATIONS Formula Ubat KKM (FUKKM) Management of reversible bronchospasm associated with obstructive airway diseases PRPA Acute asthma attack where normal inhaler therapy has failed to relieve symptoms. Expiratory wheezing associated with allergy, anaphylaxis, smoke inhalation or other lower airway cause. (with Online Medical Direction first) Exacerbation of chronic obstruction pulmonary disease (COPD) CONTRAINDICATIONS Hypersensitivity to salbutamol, ipratropium or fenoterol, atropine or its derivatives. Hypertrophic obstructive cardiomyopathy, tachyarrhythmia. PRECAUTIONS Patient with CV disorders (e.g. ischaemic heart disease, arrhythmia, severe heart failure), severe airway obstruction, cystic fibrosis, prostatic hyperplasia or bladder-neck obstruction, convulsive disorders, hyperthyroidism, diabetes mellitus. Pregnancy and lactation. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) Acute attacks: 1-unit dose vial. In severe cases not relieved by 1-unit dose vial, 2-unit dose vials may require, patient should consult a doctor immediately. Maintenance: 1-unit dose vial 3 - 4 times daily PRPA 1 vial diluted to nebulised solution total of 4mls minimum. ADVERSE EFFECTS Hypersensitivity reactions (e.g. urticaria, angioedema, rash, anaphylaxis, bronchospasm, oropharyngeal oedema), paradoxical bronchospasm, ocular complications (e.g. mydriasis, blurred vision, narrow-angle glaucoma, eye pain), serious hypokalaemia, gastrointestinal motility disturbances, rapidly worsening dyspnoea, ECG changes, lactic acidosis, urinary retention. Rarely, myocardial ischaemia. Palpitations, headache, bronchitis, cough, upper respiratory infection SPECIAL NOTES Advice responder to use N95 mask Pregnancy and children under 12 years old to inform Online Medical Direction
P A G E 3 18 5. DICLOFENAC SODIUM 75MG/3ML GROUP Nonsteroidal anti-inflammatory drug (NSAID) ACTION Competitively inhibits both COX-1 and COX-2 cyclooxygenase isoenzymes resulting in analgesic, antipyretic, and antiinflammatory effects. INDICATIONS Formula Ubat KKM (FUKKM) Pain and inflammation in rheumatic disease and of nonrheumatic origin PRPA To treat moderate to severe pain. Pain score over 5 (both tramadol and diclofenac for pain score over 5 CONTRAINDICATIONS Hypersensitivity to diclofenac, aspirin or other NSAIDs, Na metabisulphite, benzyl alcohol, propylene glycol, mannitol. History of active or suspected GI ulcers or bleeding; history of haemorrhagic diathesis, confirmed or suspected cerebrovascular bleeding; operations associated w/ high risk of haemorrhage; history of asthma. Hypovolaemia or dehydration. Concomitant use w/ anticoagulant (including low dose heparin). Moderate to severe renal impairment (serum creatinine >160 micromol/L). PRECAUTIONS Discontinue use at 1st appearance of skin rash or other sign of hypersensitivity or if GI bleeding or ulceration occurs. GI disorders, history of GI ulceration, ulcerative colitis or Crohn's disease; history of serious GI events, smoking, alcoholism. Increased risk of serious CV events eg, MI; patient w/ CV disease or risk of CV event; HTN; fluid retention or heart failure. Exfoliative dermatitis, TEN, SJS. May mask signs & symptoms of infection. Concurrent use of aspirin. Severe hepatic impairment. Not recommended during pregnancy & lactation. Not suitable for children, Elderly. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) IM 75 mg once daily (2 times daily in severe cases) for not more than 2 days. Max 150mg/day. Not suitable for children. PRPA Maximum Dose 75mg/3ML Intramuscular injection (IM) at buttock/thigh area ADVERSE EFFECTS Headache, dizziness or vertigo; epigastric pain, other GI disorders; rashes, skin eruptions; serum aminotransferase enzymes elevations; local pain & induration. SPECIAL NOTES Not suitable for children under 12 years old
P A G E 3 19 6.TABLET CLOPIDOGREL (PLAVIX) 75MG GROUP Platelet inhibitor ACTION Selectively and irreversibly inhibits adenosine diphosphate (ADP) from binding to its platelet P2Y12 receptor and subsequent ADP-mediated activation of glycoprotein IIb/IIIa complex, thus reducing platelet aggregation. INDICATIONS Formula Ubat KKM (FUKKM) Secondary prevention of atherothrombotic events in: 1. Adult patients suffering from myocardial infarction (from a few days until less than 35 days), ischaemic stroke (from 7 days until less than 6 months) or established peripheral arterial disease. Prescribing restriction: as second/third line treatment in patients who are sensitive or intolerant to acetylsalicylic acid and/or ticlopidine). 2. Adult patients suffering from acute coronary syndrome: • Non-ST segment elevation acute coronary syndrome (unstable angina or non-Q-wave myocardial infarction), including patients undergoing a stent placement following percutaneous coronary intervention. • ST segment elevation acute myocardial infarction, in combination with acetylsalicylate acid (ASA) in medically treated patients eligible for thrombolytic therapy. PRPA Use in combination with aspirin in the management of patients with acute coronary syndromes. CONTRAINDICATIONS Active pathological bleeding (e.g. peptic ulcer or intracranial haemorrhage). Severe hepatic impairment. PRECAUTIONS Patients with platelet disorders, bleeding disorders, or at increased risk for bleeding (e.g. recent trauma or surgery); lesions with a propensity to bleed (e.g. gastrointestinal, intraocular), acute lower gastrointestinal bleeding, coronary artery stents; previous hypersensitivity or haematologic reactions to thienopyridine use (e.g. ticlopidine, prasugrel). CYP2C19 intermediate and poor metabolisers. Patients undergoing CABG or other elective surgical procedures. Temporarily discontinue 5-7 days before elective surgery if antiplatelet effect is not desirable. Renal and moderate hepatic impairment. Elderly. Pregnancy and lactation. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) 75 mg once daily PRPA Oral 600mg. ADVERSE EFFECTS Cross-reactive drug hypersensitivity (e.g. rash, angioedema, haematologic reaction) among thienopyridines; prolonged bleeding time, abdominal pain. Rarely, acquired haemophilia.
P A G E 3 20 7. ADRENALINE 1mg/mL (1:1000) GROUP An active principle of the adrenal medulla, is a direct-acting sympathomimetic ACTION Stimulates α- and β-adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation and dilation of skeletal muscle vasculature. It is frequently added to local anaesthetics to retard diffusion and limit absorption, to prolong the duration of effect and to lessen the danger of toxicity. INDICATIONS Formula Ubat KKM (FUKKM) Cardiopulmonary resuscitation PRPA Cardiac arrest – shockable and non-shockable Anaphylaxis CONTRAINDICATIONS Preexisting hypertension; occlusive vascular disease; angleclosure glaucoma (eye drops); hypersensitivity; cardiac arrhythmias or tachycardia. When used in addition to local anaesthetics: Procedures involving digits, ears, nose, penis or scrotum PRECAUTIONS CV diseases; hyperthyroidism; DM; Parkinson's disease; elderly; pregnancy, lactation. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) 1 mg by intravenous injection repeated every 3-5 minutes according to response PRPA ARREST Dosage for IV ● 1mg every 2 minutes for adults ● 1ml/kg (0.01mg/kg) for paediatrics in dilution of 1:10 000 ANAPHYLAXIS Dosage for IM ● 0.3mg for adult ● 0.01mg/kg for paediatrics ADVERSE EFFECTS CNS effects; GI disturbances; epigastric pain; CV disorders; difficulty in micturition with urinary retention; dyspnoea; hyperglycaemia; sweating; hyper salivation; weakness, tremors; coldness of extremities; hypokalaemia. Gangrene, tissue necrosis and sloughing (extravasation) when used in addition to local anaesthetics. Eye drops: Severe smarting, blurred vision, photophobia; naso-lachrymal ducts obstruction. Oedema, hyperaemia and inflammation of the eyes with repeated administration.
P A G E 3 21 SPECIAL NOTES Supply: 1mg in 1ml (1:1000) 1 ampoule For paediatrics dilution of 1:10 000 is obtained by taking 1ml of adrenaline diluted to 10mls with water for injection. Please obtain medical direction for paediatrics
P A G E 3 22 8. METOCLOPRAMIDE 10MG/ 2ML (MAXOLON) GROUP Anti-emetic that enhances GI motility ACTION Stimulates the motility of the upper gastrointestinal tract and accelerates gastric peristalsis without stimulating gastric, biliary or pancreatic secretions, leading to increased gastric emptying and intestinal transit time. It blocks dopamine receptors and serotonin receptors (at higher doses) in chemoreceptor trigger zone of the CNS. INDICATIONS Formula Ubat KKM (FUKKM) Use in adults for: i) Prevention of post-operative nausea and vomiting ii) Symptomatic treatment of nausea and vomiting, including nausea and vomiting induced by migraine attacks iii) Prevention of radiotherapy-induced nausea and vomiting Use in children aged 1 to 18 years for: i) Prevention of delayed chemotherapy-induced nausea and vomiting as a second-line option ii) Prevention of post-operative nausea and vomiting as a second-line option PRPA To treat ongoing nausea, vomiting and motion sickness (if indicated) CONTRAINDICATIONS Phaeochromocytoma, GI haemorrhage, mechanical obstruction or perforation, epilepsy. Neonates, children <2 yr. PRECAUTIONS History of depression. 1st trimester of pregnancy. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) All indications (adult): A single 10mg dose is recommended for the prevention of postoperative nausea and vomiting. The recommended dose for the symptomatic treatment of nausea and vomiting, including nausea and vomiting induced by migraine attacks and for the prevention of radiotherapy-induced nausea and vomiting is 10mg per dose, 1 to 3 times daily. The maximum recommended daily dose is 30mg or 0.5mg/kg. Treatment duration when administering by injection should be as short as possible and a switch to administration via oral or rectal route should be instituted as quickly as possible. All indications (children aged 1 to 18 years of age): The recommended dosage is 0.1 to 0.15mg/kg, 1 to 3 times daily, by intravenous route. The maximum daily dose is 0.5mg/kg. Dosing table: CHILD age 1-3 years old (body weight 10-14kg):
P A G E 3 23 1mg TDS, 3-5 years old (body weight 15-19kg): 2mg TDS, 5-9 years old (body weight 20-29kg): 2.5mg TDS, 9-18 years old (body weight 30-60kg): 5mg TDS, 15-18 years old (body weight > 60kg): 10mg TDS. For the prevention of delayed CINV, the maximum treatment duration is 5 days. For the prevention of post-operative nausea and vomiting, the maximum treatment duration is 48 hours. PRPA Intravenous Injection 10mg/2ml ADVERSE EFFECTS Drowsiness, fatigue, dizziness, hyperprolactinaemia, extrapyramidal reactions. SPECIAL NOTES -
P A G E 3 24 9. HYDROCORTISONE 100MG INJECTION GROUP Steroidal anti-inflammatory. ACTION Glucocorticoid drug that reduces inflammation and suppresses the immune response. INDICATIONS Formula Ubat KKM (FUKKM) Conditions responsive to systemic or local glucocorticoid injection therapy especially in emergencies PRPA Severe or life-threatening asthma. Asthmatic patients receiving nebuliser in ambulance. CONTRAINDICATIONS Hypersensitivity. Systemic fungal infection, idiopathic thrombocytopenic purpura. Intrathecal administration. PRECAUTIONS Not to be used IA, intrabursally or for intratendinous & epidural administration for local effect. Avoid deltoid muscle injection, intrathecal route. Discontinue use in Kaposi's sarcoma patients. Not for treatment of traumatic brain injury. Not to be used in cerebral malaria & active ocular herpes simplex. Not recommended in optic neuritis. Left ventricular free wall rupture after recent MI; hypothalamic-pituitary adrenal axis suppression, Cushing's syndrome, hyperglycemia; susceptibility to infections; exacerbated systemic fungal & intercurrent infections; latent or active amebiasis; known or suspected Strongyloides (threadworm) infestation; active or latent TB; posterior subcapsular cataracts, glaucoma; CHF, HTN; active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, nonspecific ulcerative colitis; osteoporosis; neuromuscular transmission disorders eg, myasthenia gravis; psychic derangements, aggravated existing emotional instability or psychotic tendencies; pheochromocytoma. Monitor IOP in therapy >6 wk. Dietary salt restriction & K supplementation. Avoid abrupt w/drawal. Avoid exposure to chickenpox or measles. Not to be used w/ live or live, attenuated vaccine. Concomitant use w/ neuromuscular-blocking drugs e.g., pancuronium. May affect ability to drive & use machines. Renal insufficiency; cirrhosis. Pregnancy & lactation. Elderly ≥ 65 year DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) Initially 100 - 500 mg IV over 30 seconds to more than 10 minutes. Dose may be repeated at intervals of 2, 4 or 6 hours
P A G E 3 25 PRPA 4mg/kg, maximum 200mg ADVERSE EFFECTS Allergic reactions; leukocytosis; CV, dermatologic, endocrinal, GI, ophth reactions; fluid & electrolyte disturbances; -ve nitrogen balance; musculoskeletal, neurologic/psychiatric disorders. SPECIAL NOTES -
P A G E 3 26 10. HALOPERIDOL 5MG/ML INJECTION GROUP Antipsychotic ACTION Haloperidol is a butyrophenone. It nonselectively inhibits postsynaptic dopaminergic D2 receptors in the brain. INDICATIONS Formula Ubat KKM (FUKKM) Management of acute psychotic disorders including schizophrenia, manic states, and drug-induced psychosis. ii) Management of aggressive and agitated patients, including patients with chronic brain syndrome or mental retardation. PRPA: Management of aggressive and agitated patients. CONTRAINDICATIONS Severe toxic CNS depression, comatose states, Parkinson’s disease, basal ganglia lesions, thyrotoxicosis, significant cardiac disorders (e.g. acute MI, uncompensated heart failure, arrhythmias, clinically significant bradycardia, 2nd or 3rd degree heart block, uncorrected hypokalaemia). Lactation. PRECAUTIONS Patient with dementia-related psychosis, bipolar disorders, seizures or EEG abnormalities, risk of falls, risk of QT prolongation, risk factors for stroke, severe CV disease, decreased gastrointestinal motility, paralytic ileus, urinary retention, BPH, xerostomia, visual problems, and narrow angle glaucoma. Concomitant use with antidepressants and anticholinergic agents. Avoid abrupt withdrawal. Renal and hepatic impairment. Elderly. Children. Pregnancy. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) ADULT: IM or IV, 2 mg - 10 mg then every 4 - 8 hours according to response to total maximum 18 mg daily. Use in child is not recommended PRPA Sedation Dosage: 5mg Route IM Maximum offline dosage: 5mg
P A G E 3 27 ADVERSE EFFECTS Significant: Extrapyramidal syndrome (e.g. pseudoparkinsonism, akathisia, tardive dyskinesia, dystonia), CNS depression, anticholinergic effects (e.g. constipation, xerostomia, blurred vision, urinary retention), esophageal dysmotility and aspiration, somnolence, orthostatic hypotension, motor or sensory instability, hyperprolactinaemia. Cardiac disorders: Cardiac arrhythmia, tachycardia. Eye disorders: Visual disturbance. Gastrointestinal disorders: Diarrhoea, nausea, sialorrhoea, vomiting. General disorders and administration site conditions: Injection site reaction. Hepatobiliary disorders: Jaundice. Metabolism and nutrition disorders: Anorexia, hypoglycaemia. Nervous system disorders: Agitation, restlessness, headache. Psychiatric disorders: Confusion, depression, insomnia. Renal and urinary disorders: Urinary retention. Reproductive system and breast disorders: Erectile dysfunction, gynaecomastia, priapism. Respiratory, thoracic and mediastinal disorders: Bronchospasm, dyspnoea. Skin and subcutaneous tissue disorders: Acneiform rash, maculopapular rash. Vascular disorders: Hypotension. Potentially Fatal: Neuroleptic malignant syndrome, bronchopneumonia, blood dyscrasias (e.g. leucopenia, neutropenia, agranulocytosis), QT prolongation, torsade de pointes. SPECIAL NOTES If any aggressive patient require haloperidol for transportation in the ambulance, a police escort within the ambulance is required.
P A G E 3 28 11. DIAZEPAM RECTAL SOLUTION 5MG/SUPP GROUP Long-acting benzodiazepine. ACTION Diazepam is a long-acting benzodiazepine that exerts anxiolytic, sedative, anticonvulsant, muscle relaxant and amnestic effects. It binds to stereospecific benzodiazepine receptors on the postsynaptic gamma-aminobutyric acid (GABA) neuron in different regions of the central nervous system, e.g. brain and spinal cord thereby, increasing the inhibitory effects of GABA which is involved in sleep induction, control of hypnosis, memory, anxiety, epilepsy and neuronal excitability. INDICATIONS Formula Ubat KKM (FUKKM) Status epilepticus, skeletal muscle spasm PRPA Sedation seizure CONTRAINDICATIONS Acute or chronic severe respiratory insufficiency, respiratory depression, myasthenia gravis, sleep apnoea, severe hepatic insufficiency, acute narrow-angle glaucoma, phobic or obsessional states, chronic psychosis, hyperkinesis, acute porphyria. Avoid alcohol. Infants <6 months. PRECAUTIONS Patient with convulsive disorder, history of alcoholism and/or drug abuse open-angle glaucoma, cardiorespiratory insufficiency, chronic respiratory insufficiency, ataxic, obese, and debilitated patient; neurologic damage (rectal). Avoid abrupt withdrawal. CYP2C19 extensive, intermediate and poor metabolisers. Renal and mild to moderate hepatic impairment. Children and elderly. Pregnancy and lactation. Not intended as monotherapy in patients with depression, anxiety as suicide may be precipitated in such patients. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) Status epilepticus - ADULT: 0.5 mg/kg repeated after 12 hours if necessary. CHILD (febrile convulsions, prolonged or recurrent): 0.5 mg/kg (maximum 10 mg), repeated if necessary. Not recommended for children below 2 years PRPA Seizures Dosage: 0.2mg/kg (max 5mg) Maximum offline dosage: 2.5mg PR (Paediatrics only)
P A G E 3 29 ADVERSE EFFECTS Significant: Withdrawal symptoms (e.g. rebound insomnia and anxiety, panic, palpitations, sweating, paranoid psychosis, epileptic attacks, delirium), anterograde amnesia, paradoxical reactions (e.g. restlessness, agitation, irritability, aggressiveness, delusion, rages, nightmares, psychoses), habituation, drug dependence. Eye disorders: Blurred vision, diplopia. Gastrointestinal disorders: Constipation, nausea, gastrointestinal disturbances, altered salivation. General disorders and admin site conditions: Fatigue, ataxia, local reactions at the injection site e.g. thrombophlebitis and venous thrombosis. Nervous system disorders: Impaired motor ability, tremor, headache, vertigo. Psychiatric disorders: Confusion, depression, slurred speech. Renal and urinary disorders: Urinary incontinence, urinary retention. Reproductive system and breast disorders: Change in libido. Vascular disorders: Hypotension. SPECIAL NOTES Antidote: Flumazenil 0.5 mg IM route for diazepam is not recommended due to slow and erratic absorption. Pregnancy risk category D, avoided in non-life saving situations. Undergoes placental transfer.
P A G E 3 30 12. GLYCERYL TRINITRATE 0.5 MG SUBLINGUAL TABLET GROUP Vasodilator ACTION A potent vasodilator drug. Glyceryl trinitrate forms free radical nitric oxide (NO) that stimulates guanylate cyclase which increases guanosine 3’5’ monophosphate (cGMP) in the smooth muscle, resulting in dephosphorylation of myosin light chains and relaxation of smooth muscles. It reduces cardiac oxygen demand by decreasing preload and may modestly reduce afterload; dilates coronary arteries and improves collateral flow to ischaemic regions INDICATIONS Formula Ubat KKM (FUKKM) Prophylaxis and treatment of angina and left ventricular failure PRPA Cardiac chest pain due to angina or myocardial infarction. Acute cardiogenic pulmonary oedema (with medical direction) CONTRAINDICATIONS Hypersensitivity. Early MI w/ right ventricular involvement, obstructive hypertrophic cardiomyopathy, pronounced hypovolemia, severe anemia, cardiac tamponade, increased intracranial pressure. Hypotension (SBP <90mmHg). Head trauma. Cerebral haemorrhage. Sildenafil (Viagra) and other related drugs –within the previous 24 hours. Unconscious patients. PRECAUTIONS Not recommended in phenylketorunic. Pregnancy & lactation. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) 0.5-1 mg sublingually may be repeated every 5 minutes until relief is obtained. Seek physician if the pain persists after a total of 3 tablets in a 15-minute period. PRPA Route SL Adult: 500mcg Repeated dose: every 5 minutes if needed Maximum offline dose: 3 doses (1.5mg) – every 5 min each if indicated ADVERSE EFFECTS Flushing of face, dizziness, tachycardia, throbbing headache, vomiting, restlessness, blurred vision, postural hypotension, syncope. SPECIAL NOTES -
P A G E 3 31 13. ASPIRIN 300MG GROUP NSAIDS / antiplatelet ACTION Aspirin is a salicylate that exhibits analgesic, anti-inflammatory, and antipyretic activities. It is an irreversible inhibitor of cyclooxygenase-1 and 2 (COX-1 and 2) enzymes, resulting in direct inhibition of the biosynthesis of prostaglandins. It inhibits platelet aggregation via acetylation of platelet cyclooxygenase, thus irreversibly preventing the formation of platelet aggregating factor thromboxane A2. INDICATIONS Formula Ubat KKM (FUKKM) Initial treatment of cardiovascular disorders such as angina pectoris and myocardial infarction and for the prevention of cardiovascular events in patients at risk. Other such uses include the treatment and prevention of cerebrovascular disorders such as stroke. PRPA Adults with ACS CONTRAINDICATIONS Hypersensitivity to aspirin, salicylates and other NSAIDs; history of asthma attacks, angioedema, urticaria, or rhinitis precipitated by aspirin or other NSAIDs. Nasal polyps associated with asthma; active or history of recurrent peptic ulceration and gastrointestinal haemorrhage; haemorrhagic diathesis, coagulation disorders (e.g. haemophilia, thrombocytopenia), severe cardiac failure, gout. Severe renal and hepatic impairment. Children <16 years and/or those who have or are recovering from chickenpox or flu-like symptoms. Pregnancy (doses >100 mg daily during 3rd trimester) and lactation (during long-term use and/or high doses). Concomitant use with methotrexate ≥15 mg weekly. PRECAUTIONS Patient with allergic disease, asthma, chronic respiratory disease, anaemia, less severe cardiac failure, SLE, connective tissue disorders, thyrotoxicosis, hypertension, G6PD deficiency, risk factors for peptic ulcer disease (e.g. alcoholism, smoking). Patients undergoing surgical procedures, including tooth extraction. Not recommended for use during menorrhagia. Avoid use for 6 weeks following varicella vaccination. May mask signs and symptoms of infection. Concomitant use with anticoagulants (e.g. warfarin), thrombolytic, other antiplatelet agents, SSRIs, and oral corticosteroids. Avoid concomitant use with other NSAIDs. Dehydrated and debilitated patients. Mild to moderate renal and hepatic impairment. Elderly. Pregnancy (1st-2nd trimester). DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) 150mg to be taken daily. Use in children under 16 years old is not recommended
P A G E 3 32 PRPA Adult: 300mg tablet Route: oral chewed or dissolved ADVERSE EFFECTS Significant: Bronchospasm, asthma attacks, hypersensitivity reactions, prolonged bleeding time; reduced uric acid excretion (low dose use); haemolytic anaemia (in patients with G6PD deficiency), medication overuse headache (longterm use), salicylism (repeated use of large doses). Blood and lymphatic system disorders: Rarely, thrombocytopenia, agranulocytosis, aplastic anaemia. Ear and labyrinth disorders: Reduced hearing ability, tinnitus, vertigo. Gastrointestinal disorders: Dyspepsia, nausea, vomiting, diarrhoea, mild stomach pain, heartburn. Hepatobiliary disorders: Hepatic insufficiency, hepatitis. Investigations: Increased transaminases. Nervous system disorders: Headache. Renal and urinary disorders: Impaired renal function, Na and fluid retention, urate kidney stones, haematuria. Reproductive system and breast disorders: Rarely, menorrhagia. Respiratory, thoracic and mediastinal disorders: Rhinitis, dyspnoea. Skin and subcutaneous tissue disorders: Urticaria. Potentially Fatal: Gastrointestinal bleeding, ulceration, and perforation. Rarely, Reye's syndrome, serious skin reactions (e.g. Stevens-Johnson syndrome, erythema multiforme, toxic epidermal necrolysis). SPECIAL NOTES In suspected acute coronary syndrome a 300 milligram aspirin tablet should be given regardless of any previous aspirin taken that day.
P A G E 3 33 14. DEXTROSE 50%/20%/10% INJECTION GROUP Dextrose solution ACTION Glucose, the natural sugar occurring in blood, is the primary source of energy in cellular metabolism. It is readily converted to fat which provides a rich store of energy in concentrated form, and it also promotes glycogen deposition in the liver. INDICATIONS Formula Ubat KKM (FUKKM) For parenteral replenishment of fluid and minimal carbohydrate calories as required by the clinical condition of the patient PRPA Hypoglycemia CONTRAINDICATIONS Hypersensitivity to glucose, corn or corn products. Patient w/ severe dehydration, glucose-galactose malabsorption syndrome, ischaemic stroke. Admin of hypertonic soln in patients (esp if dehydrated) w/ intracranial or intraspinal haemorrhage, diabetic coma, delirium tremens. PRECAUTIONS Patient w/ DM, chronic uraemia, thiamine deficiency, severe traumatic brain injury, water and electrolyte imbalance, haemodilution, sepsis, and severe malnutrition. Avoid abrupt withdrawal. Renal failure. Childn (esp low birth wt infants). Pregnancy and lactation. DOSAGE AND ADMINISTRA TION Formula Ubat KKM (FUKKM) According to the needs of the patient PRPA ● Dose: 0.25 – 0.5g/kg. ● Maximum dose: 25g (50ml D50%) ● Route: IV ADVERSE EFFECTS Significant: Electrolyte imbalance (e.g. hypokalaemia), dehydration, severe hypersensitivity reactions (e.g. anaphylaxis). CV: Localised phlebitis, venous irritation and thrombosis, thrombophlebitis. Resp: Pulmonary vascular precipitates and oedema. Hepatic: Hepatic failure, cirrhosis, cholestasis, steatosis, increased bilirubin and hepatic enzyme, cholecystitis, cholelithiasis. Genitourinary: Diuresis. Endocrine: Glycosuria, hyperosmolar syndrome, hypervolaemia. Dermatologic: Rash. Others: Catheter infection, sepsis, chills, fever, infusion site reactions (e.g. erythema and pain). Potentially Fatal: Severe hyperglycemia and hyponatremia. SPECIAL NOTES For children, dextrose solution 10% concentration is to be used.
P A G E 3 34 15. MAGNESIUM SULPHATE 50% INJECTION (2.47g/5ML) GROUP Magnesium salts ACTION As an anticonvulsant, magnesium sulfate depresses the CNS and blocks peripheral neuromuscular transmission. INDICATIONS Formula Ubat KKM (FUKKM) i) Treatment and prophylaxis of acute hypomagnesaemia ii) Prevention and treatment of life-threatening seizures in the treatment of toxemias of pregnancy (pre-eclampsia and eclampsia) PRPA Prevention and treatment of life-threatening seizures in the treatment of toxemias of pregnancy (pre-eclampsia and eclampsia) CONTRAINDICATIONS Heart block. Renal failure (CrCl <20 mL/min). Not to be used during pregnancy 2 hr prior to delivery. PRECAUTIONS May precipitate acute myasthenic crisis. Periodically monitor serum Mg levels during therapy & urine output during 4 hr preceding dosing. Determine respiration rate prior to each dose. Test patellar reflex prior to administering repeated dose. Renal impairment. Not to be given during pregnancy 2 hr prior to delivery. Lactation. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) i) Mild hypomagnesemia (ADULT): 1gm magnesium sulphate (8mEq) IM every 6 hours for 4 doses. Severe hypomagnesemia (ADULT): 0.25 g/kg IM over 4 hours. Alternative dose of 5g may be given by slow intravenous infusion over 3 hours ii) Toxemia of pregnancy: An initial intravenous dose of 4gm of magnesium sulphate is recommended. Followed by an intramuscular dose of 4-5gm into each buttock. This may be followed by a dose of 4-5gm into alternate buttocks every 4 hours as needed. Alternatively, the initial dose IV dose may be followed by an infusion of 1-2gm/hr PRPA Intramuscular injection 2 vial per buttock (total of 4 vial) ADVERSE EFFECTS Hypermagnesaemia eg, nausea, vomiting, flushing, hypotension, muscle weakness & paralysis, blurred or double vision, CNS depression, loss of reflexes; hypocalcemia. Inj site irritation & pain. SPECIAL NOTES To inform Online Medical Direction to MECC prior to administration.
P A G E 3 35 16. SALBUTAMOL NEBULISER SOLUTION (0.5% W/V) GROUP Short acting broncodilator ACTION Salbutamol is a direct-acting sympathomimetic that acts on β2- receptors to relax bronchial smooth muscle with less prominent effect on the heart. It activates adenyl cyclase, the enzyme that stimulates the production of cyclic adenosine-3', 5'- monophosphate (cAMP). Increased cAMP leads to activation of protein kinase A, which inhibits phosphorylation of myosin and lowers intracellular ionic Ca concentrations, resulting in muscle relaxation. INDICATIONS Formula Ubat KKM (FUKKM): Indicated for the relief of bronchospasm in patients with reversible obstructive airway disease and acute bronchospasm. CONTRAINDICATIONS Hypersensitivity. Non-IV formulations: Arrest uncomplicated premature labour or threatened abortion. Inj: Conditions eg,gestational age <22 wk; intrauterine foetal death, known lethal congenital or chromosomal malformation; any condition of the mother or foetus in which prolongation of pregnancy is hazardous; patients w/ pulmonary HTN, preexisting ischaemic heart disease or significant risk factors for ischaemic heart disease; threatened abortion during 1st & 2nd trimester. PRECAUTIONS Asthma deterioration. Thyrotoxicosis. Acute severe asthma. Diabetic patients. Monitor serum K levels. Concomitant use w/ xanthine derivatives, steroids, diuretics, corticosteroids, nonselective β-blockers eg, propranolol; hypoxia. Pregnancy & lactation. Tab/syr: Underlying severe heart disease eg, ischaemic heart disease, arrhythmia, severe heart failure. Syr: Patients on controlled Na diet. Evohaler/respirator soln/nebules: Discontinue use if paradoxical bronchospasm occurs. Acute angle closure glaucoma in combination w/ ipratropium Br. Patients on largedose sympathomimetics. Respirator soln/nebules/inj: Monitor for elevated serum lactate & metabolic acidosis development. Respirator soln/nebules: Not to be inj or swallowed. Avoid contact w/ eyes. Infants <18 mth. Inj: Discontinue use if signs of pulmonary oedema or myocardial ischemia develop. Tocolysis. Assess CV status w/ continuous ECG monitoring throughout therapy. Monitor pulse rate, BP changes, electrolytes, fluid balance, glucose & lactate levels, cardioresp function. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) 2.5 to 5mg (0.5ml – 1ml), repeat according to response and tolerability. Dosing is individualised and according to product insert/protocol. ADVERSE EFFECTS Tremor, headache; tachycardia. SPECIAL NOTES -
P A G E 3 36 17. CHLORPHENIRAMINE MALEATE 10MG/ML GROUP Histamine- H1 receptor antagonist ACTION Chlorphenamine, an alkylamine derivative, is a sedating antihistamine that competitively and reversibly inhibits histamine H1- receptor in the gastrointestinal and respiratory tract and blood vessels. This prevents the release of histamine, prostaglandins and leukotrienes, and also prevents the migration of inflammatory mediators. INDICATIONS Formula Ubat KKM (FUKKM): Allergic conditions CONTRAINDICATIONS Narrow-angle glaucoma, symptomatic prostate hypertrophy, acute asthma attacks, stenosing peptic ulcer, bladder neck or pyloroduodenal obstruction. Concomitant or within 14 days of MAOI use. PRECAUTIONS Patient with CV disease (e.g. ischaemic heart disease, hypertension), increased intraocular pressure, thyroid dysfunction, asthma or other chronic breathing disorders (e.g. bronchitis), epilepsy, prostatic hyperplasia, genitourinary obstruction. Hepatic or renal impairment. Children and elderly. Pregnancy and lactation. DOSAGE AND ADMINISTRATION Formula Ubat KKM (FUKKM) 10 - 20 mg IM or SC, repeated if required. Not to exceed 40 mg in 24 hours. 10 - 20 mg over 1 minute by slow IV ADVERSE EFFECTS Significant: Sedation; excitation (in young children). Eye disorders: Blurred vision. Gastrointestinal disorders: Dry mouth, nausea, vomiting, diarrhoea, epigastric pain. General disorders and administration site conditions: Fatigue, lassitude. Metabolism and nutrition disorders: Anorexia, increased appetite. Nervous system disorders: Somnolence, disturbance in attention, abnormal coordination, dizziness, headache. SPECIAL NOTES -
P A G E 3 37 18. MORPHINE 10MG/ML INJECTION GROUP Opioid analgesia ACTION Primary effect of analgesia. Increases peripheral venous capacitance and decreases venous return. Causes euphoria and respiratory and central nervous system depression. Depressed responsiveness of alpha-adrenergic receptors (producing peripheral vasodilation) and baroreceptor inhibition. INDICATIONS Chest pain associated with ACS unresponsive to nitrates. Moderate to severe acute and chronic pain. CONTRAINDICATIONS Hypersensitivity to narcotics, hypovolemia, hypotension, severe respiratory depression. PRECAUTIONS Worsening bradycardia or heart block in inferior myocardial infarction (vagotonic effect). DOSAGE AND ADMINISTRATION Dosage: 0.2mg/kg (titrate to max 5mg) Route: IV ADVERSE EFFECTS Hypotension in volume-depleted patients, tachycardia, bradycardia, palpitations, syncope, facial flushing, diaphoresis, pruritus, respiratory depression, euphoria, bronchospasm, dry mouth, allergic reaction. SPECIAL NOTES Preparation: 10mg in one ml ampoule Pregnancy safety: Category B (if not used for prolonged periods or in high doses at term); narcotics rapidly cross the placenta. Antidote: naloxone
P A G E 3 38 19. FENTANYL 50MCG/ML INJECTION GROUP Synthetic opioid based analgesia ACTION A Mu-selective opioid agonist. Activates other opioid system receptors such as the delta and potentially the kappa-receptors. INDICATIONS To treat severe acute or chronic pain (Pain score over 7) CONTRAINDICATIONS Allergy PRECAUTIONS Allergy to other opiates DOSAGE AND ADMINISTRATION Dosage: 1-2 mcg/kg bolus (max 50mcg) May repeat to achieve reduction in pain score by 2 Route : IV ADVERSE EFFECTS Drowsiness, nausea, confusion, constipation, sedatio tolerance, addiction, respiratory depression and arres unconsciousness, coma and death SPECIAL NOTES
P A G E 3 39 20. KETAMINE 10MG/ML INJECTION GROUP A dissociative anesthetic ACTION An NMDA receptor antagonist INDICATIONS Analgesia - Burns or skeletal fractures CONTRAINDICATIONS Confusion, alcohol intoxication, significant high blood pressure acute decompensated CCF. PRECAUTIONS Liver impairment Children age less than 3 years old DOSAGE AND ADMINISTRATION Dosage: 0.5 mg/kg (max 25mg) Route : IV ADVERSE EFFECTS Hallucinations, confusion, temporary hypotension and tachycardia, hypotension, bradycardia, arrhythmias, apnoea, laryngospasm, resp depression, diplopia, nystagmus, nausea, vomiting, lacrimation, hypersalivation, raised intraocular and CSF pressure, transient rash and pain at injection site, cystitis. SPECIAL NOTES
P A G E 3 40 21. DIAZEPAM 10MG/2ML INJECTION GROUP Long-acting benzodiazepine. ACTION May potentiate the effects of GABA, depress the CNS, and suppress the spread of seizure activity INDICATIONS Sedation, seizure. CONTRAINDICATIONS Known or suspected hypersensitivity to diazepam, respiratory depression, closed-angle glaucoma PRECAUTIONS DOSAGE AND ADMINISTRATION Seizures Dosage: 0.2mg/kg (max 5mg) Maximum offline dosage: 2.5mg Route: IV ADVERSE EFFECTS Respiratory depression, hypotension SPECIAL NOTES Antidote: flumazenil 0.5 mg IM route for diazepam is not recommended due to slow and erratic absorption. Pregnancy risk category D, avoided in non-life saving situations. Undergoes placental transfer. For Online Medical Direction prior to administration.
P A G E 3 41 22. ATROPINE 1MG/ML INJECTION GROUP Anticholinergic, antispasmodic agents ACTION A competitive, reversible antagonist of muscarinic receptors with anti-sialagogue/anti-vagal effect. INDICATIONS Bradycardia Organophosphate/muscarinic poisoning CONTRAINDICATIONS Glaucoma, pyloric stenosis, thyrotoxicosis, fever, urinary tract obstruction and ileus PRECAUTIONS Not recommended for use in children. DOSAGE AND ADMINISTRATION AV block: 0.5 mg IV (0.5ml), every 3-5 minutes (maximum 3 mg) ADVERSE EFFECTS Palpitations, dilated pupils, difficulty swallowing, hot dry skin, thirst, dizziness, restlessness, tremor, fatigue, and problems with coordination. SPECIAL NOTES For Online Medical Direction prior to administration.
P A G E 3 42 23. NALOXONE HCL 0.4MG/ML INJECTION GROUP Opioid antagonist ACTION Competitive opioids receptor antagonist at mu, kappa, and sigma opioid receptors in the central nervous system (CNS) INDICATIONS Opioid Overdose - Complete or partial reversal of central nervous system and respiratory depression induced by opioids CONTRAINDICATIONS Hypersensitivity PRECAUTIONS May not reverse hypotension. DOSAGE AND ADMINISTRATION IV route: 0.4 - 2mg repeated at intervals of 2 - 3 minutes according to patient's needs; titrate until ventilation is adequate. ADVERSE EFFECTS Tachycardia, hypertension, dysrhythmias, nausea and vomiting, diaphoresis, blurred vision, withdrawal (opiate) SPECIAL NOTES Supply: 0.4mg/mL ampoule Pregnancy safety: Category C (generally considered safe for use during labor)
P A G E 3 43 24. FLUMAZENIL 0.1MG/ML INJECTION GROUP Benzodiazepine antagonist ACTION Competitively inhibits the activity of benzodiazepine and nonbenzodiazepine substances that interact with benzodiazepine receptor sites on the GABA/benzodiazepine receptor complex. INDICATIONS Benzodiazepine overdose - A complete or partial reversal of the sedative effects of benzodiazepines CONTRAINDICATIONS Hypersensitivity; Patients receiving benzodiazepine for potentially life-threatening conditions (eg. control of intracranial pressure or status epilepticus) PRECAUTIONS Head injury as it may be capable of precipitating convulsions or altering cerebral blood flow DOSAGE AND ADMINISTRATION IV route: Initial: 0.2mg over 30 seconds May give additional 0.3mg over 30 seconds (if desired level of consciousness not obtained) Further doses of 0.5 mg IV over 30 seconds may be given at 1- minutes intervals if needed to maximum total dose of 3 mg; Patients with only partial response to 3 mg may require additional slow titration to a total dose of 5 mg ADVERSE EFFECTS Dizziness, pain at injection site, increased sweating, headache, abnormal or blurred vision, nausea, vomiting, palpitations, anxiety, fear, transient hypertension, flushing, agitation, chills, sensory disturbances. SPECIAL NOTES Potentially Fatal: Cardiac arrhythmias (e.g. junctional or ventricular tachycardias), seizures.
4 SENARAI SEMAK HARIAN PASUKAN PERKHIDMATAN NO. DAFTAR KENDERAAN JENIS AMBULANS TARI SHIFT PASUKAN KVA KETUA PASUKAN PEMBANTU PASUKAN SATU PPEMBANTU PASUKAN DUA Tanggungjawab Ketua Pasukan 1. Sebarang kerosakan/kehilangan/permasalahan yang berkaita 2. Adalah menjadi tanggungjawab ketua dan ahli pasukan untuk mencukupi. 3. Setiap peralatan yang tersenarai tidak dibenarkan dikeluarka 4. Sila pastikan no. siri dan no. daftar Radicare peralatan adalah 5. Sila tukar tong oksigen jika meter regulator menunjukkan kura 6. Memastikan kuantiti peralatan dan ubatan mengikut stok yang 7. Memastikan kuantiti ubat-ubatan mencukupi dan membuat pe 8. Memastikan semua ubat-ubatan dilabel dengan tarikh luput. 9. Memastikan ubat-ubatan dan solution tidak luput / rosak.
P A G E 2 7 44 LAMPIRAN 2 AMBULANS LEMBAH KLANG A / B / C / D IKH : HARI : PAGI / PETANG / MALAM AS1 / KVAS2 / KVAS3 / KVAS4 / KVAS5 / an peralatan perubatan sila laporkan kepada penyelia bertugas. k memastikan setiap peralatan dalam keadaan baik dan n daripada ambulan yang ditetapkan. h betul. ang daripada separuh. g disenarikan. engisian semula jika stok tidak mencukupi.
4 SENARAI UBAT - UBATAN BIL NAMA UBAT JENIS KUA 1 Diclofenac 75mg/3ml Injection (A/KK) ampul 2 Tramadol 50mg/ml Injection (A) ampul 3 Morphine 10mg/ml Injection (B) ampul 4 Fentanyl 50mcg/ml Injection (A) ampul 5 Ketamine 10mg/ml Injection (B) ampul 6 Midazolam 5mg/ml Injection (A) ampul 7 Adrenaline 1mg/ml Injection (1:1000) (B) ampul 1 8 Atropine 1mg/ml Injection (B) ampul 9 Tranexamic Acid 500mg/5ml Injection (B) ampul 10 Metoclopramide 10mg Injection (B) ampul 11 Hydrocortisone 100mg Injection (C) ampul 12 Haloperidol 5mg/ml Injection (B) ampul 13 Chlorpheniramine Maleate 10mg/ml Injection (B) ampul 14 Magnesium Sulphate 2.47g/5ml Injection (C) vial 15 Naloxone HCL 0.4mg/ml Injection (B) vial
P A G E 2 7 45 TARIKH : MASA: ANTITI TARIKH LUPUT KUANTITI SEMASA DISEMAK CATAT AN 3 2 1 1 1 2 10 3 6 2 2 1 2 4 3
4 16 Flumazenil 0.1mg/ml Injection (B) vial 17 Diazepam 10mg/2ml Injection (B) ampul 18 Diazepam Rectal Solution 5mg (B) tube 19 Salbutamol Nebuliser Solution (0.5% W/V) botol 20 Combivent Nebuliser Solution (B) ampul 21 Dextrose 20% Injection in 500mls (B) botol 22 Dextrose 10% Injection in 500mls (B) botol 23 Normal Saline solution in 500mls botol 24 Normal Saline solution in 100mls botol 25 Aspirin 300mg Tablet (C) strip 26 Clopidogrel 75mg Tablet (A/KK) strip 27 GTN 0.5mg Tab (C) botol 28 Dextrose 50% Injection in 10mls (B) vial 29 Water for Injection (C+) vial 30 Lignocaine 2% Jelly (B) unit Pegawai yang memeriksa (Ketua Pas *Buat semakan semasa setiap kali pengisisan semula di mana-mana lokas Tandatangan Penyemak …………………………………… Cop & Tandatangan Tarikh :
P A G E 2 7 46 3 1 1 1 6 1 2 3 3 1 2 1 Tarikh Buka : Tarikh Luput 8/52 : 5 5 1 sukan) si penghantaran pesakit dan setiap kali pertukaran shif Tandatangan Penyelia …………………………………… Cop & Tandatangan Tarikh :