Essex Ambulance Service NHS Trust

Patient Group Direction for the

Administration of Heparin

This patient Group Direction refers specifically to the administration of the medicine Heparin. It applies solely to those named state registered paramedics who have received appropriate training, whom the Essex Ambulance Service NHS Trust employs and whose names are recorded in a ‘register of approved paramedics’ maintained by the Clinical Directorate. This Patient Group Direction is written in accordance with the Department of Health guidance on the Supply and Administration of Medicines under Patient Group Direction.

Date of effect …………………………………….

Review date ………………………………………

  1. Supply

5000 units in a 1ml ampoule

  1. Legal Status

POM

3.Description

Heparin is an anticoagulant. When given with a thrombolytic it helps to

Prevent re-thrombosis.

4.Criteria for Inclusion

Heparin is indicated for the treatment of suspected myocardial infarction with

ST elevation. It is to be given after treatment with the thrombolytic Metalyse

(Tenecteplase). The group of patients to which this Patient Group Direction applies are those who have clinical history, presentation and ECG evidence consistent with a diagnosis of acute myocardial infarction.

5.Criteria for Exclusion

  • Any patient who does not meet the inclusion criteria for treatment with Tenecteplase as stated in 4.
  • Any patients with contraindications to thrombolysis as stated in 6.
  • Any patient meeting the necessary criteria but to whom a doctor has directed that it should not be given.
  1. Contra-indications
  • Peptic ulceration within the last 6 months

Essex Ambulance Service NHS Trust

  • Bleeding. Significant trauma, Head injury, Surgery within the last 4 weeks
  • Obstetric delivery within the last 2 weeks
  • Stoke of any sort within the last 12 months/Any previous stroke with permanent disability
  • Bleeding tendency or recent blood loss (except for normal menstruation)
  • On anticoagulant therapy (Warfarin)
  • Being treated for Liver failure, Renal failure or any other severe systemic illness.
  • Hypertension (systolic >160 mmHg)
  1. Dosage

Route

/ Dose / Repeat Time / Max. Cumulative Dose
IV / 4000 units/8ml / Give once only / 4000 units

Note: IV cannula must be flushed with 10mls saline after administration of Heparin.

8.Side Effects

  • Haemorrhage
  • Anaphylaxis

Note: In the event of any side effects stop any further administration of

Heparin and Do Not Administer Teneceplase.

9.Record Keeping

Details of treatment must be recorded on the Ambulance Service Patient

Report Form PRF and Thrombolysis Proforma Checklist (TPC) in

Accordance with the local Trust policies. In all cases, a clinician at the

Receiving hospital must be informed verbally that Heparin has been administered and given a copy of the completed PRF and TPC.

  1. Signatures

This Patient Group Direction has been signed on behalf of the Essex Ambulance Service NHS Trust by:

______Anthony Marsh, Chief Executive

______Dr Adrian Noon, Medical Director

Essex Ambulance Service NHS Trust
Patient Group Direction for the

Administration of Metalyse (Tenecteplase)

This Patient Group Direction refers specifically to the administration of the medicine Metalyse (Tenecteplase). It applies solely to those named State Registered paramedics who have received appropriate training, whom the Essex Ambulance Service NHS Trust employs and whose names are recorded in a ‘Register of Approved Paramedics’ maintained by the Clinical Directorate. This Patient Group Direction is written in accordance with the department of Health guidance on the Supply ad Administration of Medicines under a Patient Group Direction.

Date of effect ……………………………………….

Review Date…………………………………………

1.Supply

Vials containing 10,000 units (50mg) Tenecteplase plus 10ml water in a pre-filled syringe. Final solution will have 1000 units/ml in marked 1ml aliquots.

2.Legal Status

POM

  1. Description

Tenecteplase binds to the fibrin component of the thrombus and selectively

converts thrombus-bound plasminigen to plasmin, which degrades the fibrin

matrix of the thrombus.

4.Criteria for inclusion

  • Acute myocardial infarction (AMI) within 6 hours of the onset of AMI symptoms
  • All the questions on the pre-hospital Thrombolysis assessment document must be ticked ‘YES’
  • Adults who are > 18 years old.
  • Patients must be read the Pre-Thrombolysis Consent Information and consent granted prior to administration.
  1. Criteria for exclusion
  • Any patient who does not meet the inclusion criteria
  • Any patient with contra-indications as stated in primary/secondary assessments

Essex Ambulance Service NHS Trust

  • A patient meeting the necessary criteria but to whom a doctor has directed it should not be given
  • Patients less than 18 years old
  • Patients with a known sensitivity to tenecteplase

5.Primary Assessment – For Eligibility for Thrombolysis

5.1Can you confirm that the patient is conscious, coherent and able to?

Understand that a clot-dissolving drug will be used?

5.2Can you confirm that the patient is aged 75 or less?

5.3Can you confirm that the patient has had symptoms characteristic of a coronary heart attack (i.e. pain in a typical distribution of 15 minutes or more)?

5.4Can you confirm that the symptoms started less than 6 hours ago?

5.5Can you confirm that the pain built up over seconds and minutes rather than starting totally abruptly?

5.6Can you confirm that breathing does not influence the severity of the pain?

5.7Can you confirm that the heart rate is between 50 and 140?

5.8Can you confirm that the systolic blood pressure is more than 80mmHg and less than 160mmHG?

5.9Can you confirm that the ECG shows abnormal ST elevation of 2mm or more in at least 2 standard leads or in at least 2 adjacent pericardial leads not including V1? (ST elevation can be normal in V1 and V2)

5.10Can you confirm that Left Bundle Branch Block is absent from thereading?

Secondary Assessment – To Exclude Contra-indications to Teneceplase

5.11 Can you confirm that there is no atrio-ventricular block greater?

than 1st Degree? (If necessary after treatment with IV atropine)

5.12 Can you confirm that the patient is not likely to be pregnant, nor

has delivered within the last 2 weeks?

5.13Can you confirm that the patient has not had a peptic ulcer within

The last 6 months

5.14 Can you confirm that the patient has not had a stroke of any sort

In the last12 months and no permanent disability from a previous stroke?

5.15Can you confirm that the patient has no diagnosed bleeding tendency, has had no recent blood loss (except for normal menstruation) and is not taking warfarin (anticoagulant) therapy?

5.16Can you confirm that the patient has not had any surgical operation, tooth extractions, significant trauma, or head injury within the last 4 weeks?

5.17Can you confirm that the patient has not been treated recently for any other serious head or brain condition? (This is intended to exclude patients with cerebral tumours).

Essex Ambulance Service NHS Trust

5.18Can you confirm that the patient is not being treated for liver or renal

Failure, or any other severe systemic illness?

6.Dosages

Patients body weight
Category (KG) / Tenecteplase units / Corresponding volume of
Reconstituted solution (ml)
<60 / 6000 / 6
>60 to <70 / 7000 / 7
>70 to <80 / 8000 / 8
>80 to <90 / 9000 / 9
>90 / 10000 / 10

Note: Heparin must be administered immediately prior to Tenecteplase as per PGD on Heparin

WARNING:Tenecteplase should not be administered Intramuscular or Subcutaneous as it increases the risk of local bleeding.

  1. Side Effects
  • Possible death and permanent disability from Cerebral haemorrhage/Haemorrhage (incident <1:100)
  • Arrhythmia including VT, VF or EMD
  • Cardiogenic, Re-infarction, Pulmonary/Systemic and Cerebral embolism
  • Confusion, Agitation, Delirium, Speech Disorder, Seizures and Anaphylaxis

In the event of any side effects stop any further administration of Tenecteplase. If BP below 90 systolic, elevate legs.

  1. Further Advice

If the Paramedic is uncertain of the clinical findings, or whether the patient fulfils the requirements the primary and secondary assessments they MUST seek advice from a doctor at the receiving unit or withhold the drug.

10.Follow Up

Any patient treated with a drug under this PDG must be left in the charge of

Staff at the hospital, having given a thorough hand-over and ensuring the nurse is aware that Heparin and Tenecteplase have been given. This hand-

Over may take place in the Accident and Emergency Department or in the Coronary Care Unite, depending upon local protocols.

Essex Ambulance Service NHS Trust

to ensure that it is obvious the patient has received a thrombolytic drug, the administering paramedic will place a yellow fluorescent armband on the patient’s wrist.

  1. Additional Information
  • Do not delay transportation to hospital if difficulties arise setting up the equipment or establishing IV access.
  • If the patient is already on heparin, tenecteplase can be administered but exclude the follow up bolus dose of heparin.
  1. Record Keeping

Details of treatment must be recorded on the Ambulance Service Patient Report Form and Thrombolysis Proforma Checklist in accordance with local Trust Policies. In all cases, a clinician at the receiving hospital must be informed verbally that Tenecteplase has been administered and given a copy of the documentation.

  1. Signatures

This Patient Group Directive is signed on behalf of the Essex Ambulance Service NHS Trust by:

______Anthony Marsh, Chief Executive

______Dr Adrian Noon, Medical Director