Emergency medications Prepared by: Mesgana Dereje Moderator – Dr. Milkiyas Outline • Introduction • CVS emergency drugs • CNS emergency drugs • Respiratory emergency drugs • Drugs related to Metabolism & electrolytes • Poisoning Management Introduction • Emergency physicians care for unscheduled and undifferentiated patients of all ages. • Proper knowledge and expertise handling of emergency medications can dramatically change the clinical outcome of a patient. • Most work by maintaining physiologic stability. Medications for Cardiogenic Emergency Epinephrine • Sympathomimetic • MOA - Agonist of β1, β2, α1, α2 • Dosage- 0.2 – 0.5 ml s/c or IM - 0.5 ml intra-cardiac • Indications - Cardiac arrest, Symptomatic bradycardia, Anaphylactic shock , Severe asthmatic attack • Adverse reaction - palpitation, headache, If injected rapidly or iv causes marked increase in BP Dobutamine Hydrochloride • MOA • Positive inotropic and chronotropic effects • Dosage – continuous IV infusion, 2 to 20 microgram/kg/min • Indications • Cardiogenic shock, CHF • Adverse reactions • dyspnea, tachycardia, chest pain • Contraindications • severe hypotension Dopamine Hydrochloride • MOA • Chronotropic effect and increase stroke volume • It can increase heart rate when atropine has not been effective • Dose: 5-20mcg/kg/min, continuous IV - Extravasation can lead to tissue necrosis • Indications • Cardiogenic and septic shock, hypotension with low cardiac output states • Adverse reactions • Headache, anxiety • Contraindications • tachydysrhythmias Atropine Sulfate • Mechanism of action • competitive antagonist at muscarinic receptor • Increases HR in life-threatening bradydysrhythmias • Indications • unstable bradycardia • Adverse reaction- Headache, Anxiety, Dyspnea ,Palpitations, Hyperthermia • Contraindications- Tachycardia, hypersensitivity Medication for Respiratory Emergencies Ipratropium • Mechanism of action • muscarinic antagonist • Inhibits interaction of acetylcholine at receptor sites of bronchial smooth muscle Indications • Persistent bronchospasm, COPD exacerbation • Contraindications • Hypersensitivity to ipratropium • Adverse reactions • Headache, dizziness, sedation, fatigue, dry mouth Route of administration - inhalation Hydrocortisone Sodium Succinate • Mechanism of action • Anti-inflammatory; immunosuppressive with salt-retaining actions • Indications • Shock due to acute adrenocortical insufficiency, anaphylaxis, asthma, and COPD • Contraindications • Systemic infections, premature infants, HTN • Adverse reactions • Decreased wound healing • Hypertension • Gastrointestinal bleeding oxygen • Mechanism of action • Reverses hypoxemia • Reduce the size of infarcted tissue during acute MI • Indications Respiratory distress from any cause. Ischemic chest pain/ acute MI Confirmed or suspected hypoxemia Shock Suspected stroke Major Trauma. Carbon monoxide poisoning. • Adverse reactions Decreased level of consciousness (COPD patients) CAUTION IN COPD PATIENTS • May lose their hypoxic respiratory drive • Certain patients with COPD will not tolerate oxygen concentrations over 35%. CNS emergency medications Mannitol • Is an osmotic diuretic • Induces diuresis by elevating osmolarity of the glomerular filtrate • Hinders tubular reabsorption of water Indication and dosage Cerebral edema – IV infusion 1.5 – 2g/kg infused in 30-60 min Elevated ICP – IV infusion as 1.5 – 2 g/kg infused in 30-60 min • Contraindications cerebral hemorrhage, pulmonary edema, severe dehydration, CHF. • Consider not to store at cool temperatures as it could crystallize Diazepam • Modulates post synaptic effects of GABA-A transmission • Hence raises the seizure threshold. Indications -Generalized tonic clonic seizures, status epilepticus -Acute anxiety states and alchol withdrawals Consideration Category D in pregnancy • Adverse reactions • Dizziness, confusion, headache, CNS depression, Withdrawal symptoms Magnesium Sulfate • MOA - Produce anticonvulsant effect by reducing Ach release at end plate - Promotes movement of K, Ca, Na in and out and stabilize excitable membranes • Indication and dosage - Tx of Convulsions – IV MgSO4 indicated for immediate control of life threatening convulsions of pregnancy - 1-4g MgSO4 given IV in 10% to 20% solution Morphine • Narcotic analgesic • Alleviates pain through CNS action • Readily crosses the placenta Indication and dosing Management of surgical pain 1-4 mg IV over 1-5min to be repeated up to every 30 mins until pain is relieved Emergency medications used in OB/GYN OB/GYN Emergency drugs • i) Uterotonics and tocolytics Uterotonics – increase uterine contractions (e.g oxytocin, prostaglandins, serotonine and cathecolamines) - Indicated also for post partum hemorrhages Tocolytics – decrease uterine contractions (e.g anti oxytocin drugs, spasmolytics) Severe Pre eclampsia • IV labetalol – B blocker - contraindication- Asthmatics , Marked bradycardia • IV hydralazine - Arterial vasodilator - Side effects include headache, nausea, vomiting, tachycardia, hypotension Medicines for correcting water, electrolyte and acid – base disturbances • IV fluids • Normal saline • Ringer’s lactate • 5% Dextrose in Lactated Ringer’s (D5LR) • Magnesium sulphate: Relieve constipation (PO) 0.9% Sodium Chloride (Normal Saline) • Mechanism of action • Replaces water and electrolytes • essentially isotonic and iso osmolar • distributed to the ECF • Indications • Heat-related problems (heat exhaustion, heat stroke), hypovolemia • Contraindications • Should not be used in patients with congestive heart failure • Adverse reactions • Rare in therapeutic dosages • Considerations • None • Dose • Usually 10 ml/kg as an IV bolus repeated if necessary Lactated ringer (Hartmans solution) • Mechanism of action • Replaces water and electrolytes • Ions same as in ECF • Indications • Hypovolemic shock; keep open IV • Substitutes 0.9% saline • Contraindications • Should not be used in patients with congestive heart failure • Adverse reactions • Rare in therapeutic dosages • Considerations • None MEDICINES FOR POISNING AND OVERDOSE Management • Control the airway, ventilation and oxygenation. • ECG, VS, and neurologic status • monitored for changes. • Note for • amount • time since ingestion • signs and symptoms • age and weight • health history are determined. Options for management • Give water or milk - for dilution not attempted if patient has acute airway obstruction, or if with evidence of gastric or esophageal burn or perforation. • Ipecac syrup - induce vomiting in the alert patient • Gastric lavage • Activated charcoal administration if poison can be absorbed by it Common Antidotes 1. 2. 3. NALOXONE – anti-dote for opiates overdose FLUMAZENIL – reverses respiratory depression secondary to benzodiazepines ATROPINE - reverses organophosphate poisoning Reference Basics of Anesthesia, 6th edition Kaplan lecture notes pharmacology, 2017 Ronald D. Miller. 2015. Miller’s anesthesia, 8th edition Charles A. Vancanti. 2011. Essential Clinical Anesthesia THANK YOU
