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Compound Sodium Lactate

(Hartmann’s) is used to replace

body fluid and mineral salts that

may be lost for a variety of medical

reasons. It is especially suitable

when the losses result in too much

acid being present in the blood.

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IM: 500 micrograms of ergometrine and 5 units of oxytocin in 1ml

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Sodium ions – 131 mmol

Chloride ions – 111 mmol

Calcium ions – 2 mmol

Potassium ions – 5 mmol

Lactate – 29 mmol

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Initial dose 250ml with a repeat dose of 250ml the dose interval is as and when, the max dose of sodium chloride is 2 litres. Concentration is 0.90% and volume 250ml

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Can also be given IV if bleeding is severe. (however not recommended)

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Post-partum haemorrhage (PPH) within 24 hours of birth where bleeding from the uterus is uncontrollable by uterine massage and use of Syntometrine.

Life-threatening obstetric bleeding less than 24 weeks pregnant where a miscarriage has been confirmed (e.g. confirmed by ultrasound scan, or when a miscarriage is being managed at home with medical treatment or a fetus has definitely been passed and seen). Life-threatening bleeding is normally more than 500mls OR when signs of shock are present.

NB
Miso
prostol should only be used if other oxytocics are unavailable or if they have been ineffective at reducing haemorrhage after 15 minutes.

NB
Miso
prostol should be used as first-line drug treatment for PPH in pre-eclampsia or hypertension where BP is 140/90 mmHg or more (or where systolic BP alone is 150 mmHg or more). Syntometrine (ergometrine and oxytocin) is contra-indicated in hypertension.

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Compound Sodium Lactate (Hartmanns) infusion solution is contraindicated in patients with:

-A known hypersensitivity to sodium lactate

-Congestive heart failure or severe impairment of renal function

-Clinical states in which the administration of sodium and chloride is detrimental

-DKA coma and pre coma

-Neonates

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Diluent for oxytocin infusion:

Sudden drop in systolic blood pressure.

Replacement of fluid to maintain circulatory volume until blood is

available as per local guidelines for postpartum haemorrhage.

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Given if systolic BP is <90mmhg and signs of poor perfusion

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Given if systolic BP is <90mmhg and signs of poor perfusion

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Pharmacology of Hartmann’s
A multiple electrolyte intravenous solution is intended for restoring the electrolyte balance and water for hydration. A combination of multiple electrolytes and sodium lactate, an alkalinising agent, will provide electrolyte balance and normalise the pH of the acid-base balance of the physiological system.

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Sodium (salt) causes arterial constriction and increases vascular resistance, increasing cardiac output and improves perfusion.

due to arterial constriction and the increase of vascular resistance, it is able to rehydrate the body and help prevent shock. This is because is reduces hypotension and allows the body to stop compensating, so BP can decrease as well as the RR.

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Post-partum haemorrhage within 24 hours of delivery of the infant where bleeding from the uterus is uncontrollable by uterine massage.- Miscarriage with life threatening bleed and a confirmed diagnosis (e.g. where a patient has gone home with medical management and starts to bleed)

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The lactate is is metabolised into bicarbonate , mainly in the liver and produces an alkalinising effect on the plasma.

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Indications

·         Used for the management of the last stage of labour aka third stage, for the delivery of placenta.

·         Also the prevention and control of bleeding post-delivery.

·         It causes the uterus to contract. It stimulates the womb to contract which helps the placenta to separate from the womb which reduces the risk of heavy bleeding.

·         It can be given after the placenta is given purely to prevent or control heavy bleeding.

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Both upper and lower uterine segments are stimulated to contract in a tetanic manner. Unlike oxytocin, ergometrine has an effect on the non-pregnant uterus.

Tetanic contraction: the result of repeated stimuli at such short intervals that the muscle fiber (or muscle) doesn't have time to fully relax before it is called upon to contract again.

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Dose for an adult 1gram, no repeat dose. 100mg/ml. Dose interval N/A.

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Known hypersensitivity to Syntometrine

In labour, prior to the birth of the baby

Severe cardiac, liver or kidney disease-

Hypertension and severe pre-eclampsia-

Possible multiple pregnancy/known or suspected fetus in utero.

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Increases vascular fluid volume which also raises cardiac output and improves perfusion

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Over-infusion can lead to pulmonary oedema and cause breathlessness

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General medical conditions without haemorrhage:

-Initial dose: 250ml

-Max dose: 1l

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TXA inhibits fibronolysis by competing with fibrin for the lysine binding sites in plasminogen. TXA inhibits the capacity of plasminogen and plasminogen to bind to fibrin, hence preserving blood clots from plasminogen - mediated lysis

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Actions:-	                                                                          

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Actions:-	                                                                          

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Stimulates contraction of the uterus

Onset of action 7-10 minutes

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Dose
Initial dose for adults for flush 2-5ml max n/a
Medical emergencies - general 250ml max 2litres
Medical emergencies - sepsis 500ml max 2litres
DKA - 500ml - max 1 litre
Haemorrhage - 250ml - max 2 litres
Adult trauma blunt - 250ml - max 2 litres
Penetrating torso trauma - 250ml - max 2 litres 2 litre
Burns - 1 litre -max 1 litre
Crush syndrome - 2 litres - max 2 litres
Child medical emergencies- different ages

Presentation
100ml,250ml,500ml and 1000ml packs

5ml and 10ml ampoules for flush

Indications
Adult fluid therapy
Child fluid therapy
Flush

Pharmacodynamics
Sodium and chloride ions in maintaining the fluid and electrolyte balance.

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Route - sublingual (unless the patient is unable to maintain their own airway) OR rectal (at the time of publication there is no rectal preparation of Misoprostol - therefore the same tablets can be administered sublingually or rectally.)

The vaginal route is not appropriate in post-partum haemorrhage or for miscarriage, but the rectal route may be considered when appropriate (e.g. impaired consciousness).

Dose - 800mcg (4x200mcg tablets)

No repeat dose.

Concentration 200mcg per tablet.

Max dose 800mcg.

Misoprostol is not recommended for administration to patients aged 11 or under.

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-       Anaphylaxis in women with latex allergy – There have been reports of anaphylaxis following administration of oxytocin in women with a known latex allergy. Due to the existing structural homology between oxytocin and latex, latex allergy/intolerance may be an important predisposing risk factor for anaphylaxis following oxytocin administration.

-       If bleeding is not arrested, consider possibility of retained placental fragment, or soft tissue injury (cervical or vaginal laceration), or clotting defect and take appropriate measures.

-       Vasoconstriction and rarely acute pulmonary oedema.

-       Mild or moderate hypertension, cardiac, liver or kidney disease (contra-indications if severe) – women with coronary artery disease may be more susceptible to angina or myocardial infarction.

-       History of QT prolongation syndrome (see medicine interactions).

-       Acute porphyria.

-       Multiple pregnancy – should not be given until after delivery of the last baby.

-       Raynaud’s disease.

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common side effects more than 1 in 100 but less than 1 in 10

-nausea
-vomiting
-diarrhoea

serious adverse effects
-hypersensitivity reactions. (anaphylaxis)
-rapid injection can cause hypotension
-arterial or venous embolism.

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Patients with signs of actual or suspected severe haemorrhage in the following clinical scenarios:
- injured patients triggering local network major trauma criteria.
- head injury patients, ages 18 and over with a GCS of 12 or less.
- patients with a TIME CRITICAL injury where significant internal or external haemorrhage is known or suspected.
- post-Partum haemorrhage if the patient continues to bleed.

Trauma:
Treatment of known or suspected severe traumatic internal or external haemorrhage as soon as clinically possible on arrival at the scene and within 3 hours of bleeding starting in adults and children who are considered to be at risk of significant haemorrhage. This may be demonstrated by one or more of:
- systolic blood pressure < 90mmHg or absent radial pulse or heart rate > 110 bpm believed to be due to bleeding in adults.
- any patient with haemostatic gauze, arterial tourniquet/s, chest dressing/s or pressure dressing/s have been applied.
- patient who has suffered a traumatic cardiac arrest.

The above would include women who have recently given birth but have suffered subsequent trauma.

Women who are pregnant and/or breastfeeding should have tranexamic acid administered in life threatening haemorrhage.

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-       Nausea and vomiting

-       Abdominal pain

-       Headache

-       Hypertension and bradycardia

-       Chest pain and rarely anaphylactic reactions

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Syntometrine is used to help contractions during birth in a tetanic manner and after birth. A tetanic manner (repeated stimuli at short intervals, not allowing the muscle fibre to relax fully before it contracts again) is when the womb muscles are stimulated to produce the rhythmic contractions during childbirth

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Syntometrine and misoprostol reduce bleeding from a pregnant uterus through different pathways; therefore, if one drug has not been effective after 15 minutes, the other may be administrated in addition.

Must be stored in a fridge at a temperature 2-8 degrees and once removed must be stored in a dark place, for no longer than two months.

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Syntometrine combines the rapid uterine action of oxytocin, a nonapeptide hormone released by the posterior lobe of the pituitary, with the sustained uterotonic effect of ergometrine.

Ergonovine directly stimulates the uterine muscle to increase force and frequency of contractions. With usual doses, these contractions precede periods of relaxation; with larger doses, basal uterine tone is elevated and these relaxation periods will be decreased. Contraction of the uterine wall around bleeding vessels at the placental site produces hemostasis. Ergonovine also induces cervical contractions. The sensitivity of the uterus to the oxytocic effect is much greater toward the end of pregnancy. The oxytocic actions of ergonovine are greater than its vascular effects. Ergonovine, like other ergot alkaloids, produces arterial vasoconstriction by stimulation of alpha-adrenergic and serotonin receptors and inhibition of endothelial-derived relaxation factor release. It is a less potent vasoconstrictor than ergotamine. As a diagnostic aid (coronary vasospasm), ergonovine causes vasoconstriction of coronary arteries.

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It was found that in a prehospital setting that it is no more beneficial to use a blood transfusion than sodium chloride, for major haemorrhages.

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-known previous anaphylactic reaction to TXA
-bleeding started more than 3 hours ago
-obvious resoulation of haemorrhage
-critical intervention required ( must only be givem after critcal intervetions have been performed; i.e airway managed, conrol or spliting of major haemorrhage etc. and if administered =, noting it may be administered en route)

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combines rapid uterine contraction oxytocin (hormone released in pituitary) with the sustained uterotonic effect of ergometrine.

Uterotonic meaning to strengthen contractions in pregnant women. Oxytocin activates sensory nerves during labour.

Ergometrine increases the amplitude and frequency of uterine contraction and uterine tone which in turn impedes uterine blood flow. The contraction of the uterine wall produces haemostasis.

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Special warnings and precautions 

Syntometrine should not be given until after delivery of the child, and in multiple births not until the last child has been delivered 

Women with decreased kidney or liver function 

Patients with coronary artery disease may be more susceptible to angina or myocardial ischaemia and infarction caused by ergometrine-induced vasospasm  

Caution is required in patients with mild or moderate hypertension, cardiac disorder, or hepatic or renal impairment 

Oxytocin should be considered as potentially arrhythmogenic. Caution is required when using Syntometrine in patients with other risk factors for torsades de pointes such as drugs which prolong the QT interval or in patients with a history of long QT syndrome 

Inherited blood disorders called porphyrias 

In postpartum haemorrhage, if bleeding is not arrested by the injection of Syntometrine, the possibility of retained placental fragments, of soft tissue injury (cervical or vaginal laceration), or of a clotting defect, should be excluded before a further injection is given 

It can also suppress lactation, so repeated use should be avoided 

There have been reports of anaphylaxis following administration of oxytocin in women with a known latex allergy. Due to the existing structural homology between oxytocin and latex, latex allergy/intolerance may be an important predisposing risk factor for anaphylaxis following oxytocin administration. 

Ergometrine can cause vasoconstriction and should therefore be used with caution in patients with Raynaud's phenomenon. 

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Misoprostol stimulates prostaglandin receptors in the uterus causing contractions of the womb know as uterotonics

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Allergies to oxytocin, ergometrine, latex
High blood pressure- causes vasoconstriction, which increases blood pressure further
Kidney, liver or heart disease
Multiple pregnancies

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A - in small intestine

D - 100% bioavailability as given IV

M - salt is taken into GI tract, remaining unabsorbed as the liquid contents pass through stomach and small bowel. Then passes through the colon where salt is taken into the blood.

E - Excess excreted by kidneys

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Patients with signs of actual or suspected severe haemorrhage in the following clinical scenarios:

-Injured patients triggering local network major trauma criteria.
-Head injury patients, aged 18 and over with a GCS of 12 or less.
-Patients with a time critical injury where significant internal or external haemorrhage is known or suspected.
-Post-partum haemorrhage if the patient continues to bleed.

Trauma:

Treatment of known or suspected severe traumatic internal or external haemorrhage as soon as clinically possible on arrival at the scene and within 3 hours of bleeding starting in adults and children who are considered to be at risk of significant haemorrhage. This may be demonstrated by one or more of:

-Systolic blood pressure < 90mmHg or absent radial pulse or heart rate > 110 bpm believed to be due to bleeding in adults. In children this may be demonstrated by changes in the normal physiological parameters for age.
-Any patient where haemostatic gauze, arterial tourniquets, chest dressings or pressure dressing have been applied.
-Patient who has suffered with a traumatic cardiac arrest.

The above would include women who have recently given birth but have suffered subsequent trauma.
Women who are pregnant and/or breastfeeding should have tranexamic acid administered in life-threatening haemorrhage.

Head injury

Patients aged 18 and over who have a known or suspected head injury where the following criteria is met:

-The GCS is 12 or less.
-The injury has occurred within the last 3 hours.

Post-Partum haemorrhage

Either of the following criteria:
-Woman who has given birth within 3 hours, with post-party’s haemorrhage causing haemodynamic instability (has lost 500ml or more of blood) and bleeding is continuing.
-Women with a post-partum  haemorrhage when uterine trauma (rupture) is suspected.
-Women who are breastfeeding should have TXA administered in life-threatening haemorrhage.

Actions:

Tranexamic acid is an anti-fibrinolytic which reduces the breakdown of blood clot.

Contraindications:

-Known previous anaphylactic reaction to TXA.
-Bleeding started more than 3 hours ago.
-Obvious resolution of haemorrhage.
-Critical interventions required (must only be given after critical interventions have been performed, i.e. airway managed; control or splinting of major haemorrhage ect. And if administration does not delay transfer, noting it may be administered en route).

Route:

IV - Administer slowly over 10 minutes - can be given as 10 aliquots administered 1 minute apart.
IM - Where IV access is not achievable promptly, and the IO route is not appropriate, the IM route can be considered into a large muscle (or in divided doses for small muscle mass, e.g. for an adult, 2 x 5ml IM at separate sites).
Post-partum  haemorrhage in women - a second dose can be administered if bleeding continues after 30 minutes of the first dose being administered. Any further doses are not permissible with 24 hours.

Cautions:

-Patients with a known history of convulsions or convulsions from any cause during the incident. High dose regimes have been associated with convulsions; however, in the low dose regime recommended here, the benefit from giving TXA for severe haemorrhage outweighs the risk of convulsions. An increase in convulsion rate may be due to the antagonistic effect of TXA on GABA receptors.

Patients with a known history of acute venous or arterial thrombosis. In the low dose regime recommended here, the benefit of giving TXA for severe haemorrhage outweighs the risk of thrombotic events. This information should be passed to the receiving hospital.

Side effects:

-Nausea
-Vomiting
-Diarrhoea

-Hypersensitivity reactions including anaphylaxis have been reported
-Rapid injection may cause hypotension
-Arterial or venous embolism at any site

Dose:
Initial dose: 1 gram
Repeat dose: NONE
Volume: 10ml
Max dose: 1 gram

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Any bleeding in pregnancy if there is any suspicion that the fetus or embryo is in the uterus (‘in utero’).

In labour, prior to the birth of the baby (with a multiple pregnancy, ensure all babies have delivered).Known hypersensitivity to

misoprostol.

Secondary post-partum haemorrhage (excess bleeding more than 24 hours after delivery of the baby).

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A - Tablet form administered sublingual, reduced consciousness can be given pr

D - sublingual with 10 mins to effect. Bioavailability as is extensively absorbed. Highly protein bound

M - 1st pass metabolism in liver with half life of 20-40 mind

E - Expelled in urine.