SURGERY
BAPUJI DENTAL COLLEGE AND HOSPITAL
SEMINAR
ON
EMERGENCY DRUGS
Moderator:
Dr. Dayananda
Presenter:
CONTENTS
1. INTRODUCTION
2. EMERGENCY DRUG KIT
3. EMERGENCY DRUG MODULES OR LEVELS
4. EMERGENCY DRUGS IN
- Cardiovascular system
- Respiratory system
- Central Nervous system
- Endocrine system
- Allergic reactions.
5. OTHER
EMERGENCY
DRUGS
EMERGENCIES
6. CONCLUSION
7. REFERENCES.
USED
IN
DIFFERENT
INTRODUCTION
An emergency is a serious situation that arises suddenly and threatens
the life or welfare of a person or a group of people, as a natural disaster or a
medical crises.
Emergency department is a section of an institution that is staffed and
equipped to provide rapid and varied emergency care, especially for those
stricken with sudden and acute illness or those who are the victims of severe
trauma.
In spite of the most meticulous protocols designed to prevent the
development of life- threatening situations, emergencies still occur.
Prevention, as successful it may be, is not always enough. The entire office
staff must be prepared fully to assist in the recognition and management of
any potential emergency situation.
The management of an emergency begins with the application of the
steps of basic life support: P (positioning), A (airway), B (breathing), C
(circulation) and D (definitive treatment), including the administration of
drugs and hence emergency drugs and equipment must be available in every
dental office.
EMERGENCY KITS
A number of emergency kits are available commercially for the in the
dental and medical offices. The best emergency drug kit is one the doctor
designs personally to meet his special requirements and capabilities. The
emergency kit should not be complicated. It should be as simple as possible
organized collection of drugs and equipment that is highly effective in the
management of life- threatening situations.
Pallachs statement that complexity in a time of adversity breeds
chaos is all true.
The doctor should remember three things in preparing and using
emergency drug kits:
i)
ii)
iii)
All the drugs come with drug package inserts. Doctors should save this
information sheet from each drug included in their kit, read it, and take a
note of important information about the drug, including its indications, usual
doses (pediatric, adult and geriatric), adverse reactions, and expiry dates.
EMERGENCY DRUGS
The emergency drugs and equipment are now described according to
four levels or modules.
Module one: basic emergency kit (critical drugs and equipment)
Module two: non critical drugs and equipment
Module three: ACLS
Module four: antidotal drugs
Two categories of drugs are described for each module as well as
emergency equipment:
1) Injectable drugs
2) Non-injectable drugs
Most Injectable drugs are prepared in a 1-ml glass ampule or vial. The
number of mgs of drug present in 1 ml of solution varies from drug to drug.
E.g. diazepam is 5mg/ ml, whereas diphenhydramine is 50 mg/ ml and
ephedrine is 10 mg/ ml. the one ml form of the drug is known as its
therapeutic dose or unit dose. However, epinephrine is a major exception to
this basic rule of doses. Although the 1- ml form of 1: 1000 epinephrine is
considered the adult therapeutic dose, a smaller dose- 0.3 ml- is
recommended, with subsequent doses based on patients response.
Noninjectable drugs usually are prepared so that one tablet or spray is
the adult therapeutic dose. Many of them are also prepared in pediatric
forms to simplify administration.
Other items of emergency equipment should be available in both
pediatric and adult forms. E.g. face masks, airways etc.
Epinephrine
ii)
Histamine blockers
Chlorpheneramine
Dipenhydramine
Noninjectable drugs:
i)
Oxygen
ii)
Vasodialators
Nitroglycerine
Amyl nitrate
iii)
Bronchodialator
Albuterol
Metaproterol
iv)
Antihypoglycemics
v)
Asprin
Emergency equipment:
i)
ii)
iii)
Tourniquets
iv)
Syringes
v)
Anticonvulsants
Midazolam
diazepam
ii)
Analgesics
Morphine sulphate
Meperidine
iii)
Vasopressors
Methoxamine
Phenylephrine
iv)
Antihypoglycemics
Dextrose 5%
Glucagon
v)
Corticosteroids
Hydrocortisone sodium succinate
vi)
Antihypertensives
Esmolol
propranolol
vii)
Anticholinergics
atropine
Noninjectable drugs:
i)
Respiratory stimulant
Aromatic ammonia
ii)
Antihypertensives
8
Nifedipine
Nitroglycerine
Emergency equipment:
i)
ii)
Artificial airways
iii)
Epinephrine
ii)
Oxygen
iii)
Lidocaine
iv)
Atropine
v)
Dopamine
vi)
Morphine sulphate
vii)
Verapamil
Opioid antagonist
Naloxane
Nalbuphine
ii)
Benzodiazepine antagonist
Flumazenil
iii)
iv)
Therapeutic considerations :
- Acute allergic reaction.
- Acute asthmatic attacks.
- Cardiac arrest.
Side effects, contraindications precautions :
- Tachyarrhythmias, both supraventicular and ventricular may develop.
- Epinephrine should be used with contain in pregnancy because it
decreases placental blood flow and may induce premature labor.
- An vital signs should be frequently monitored
Availability :
- Epinephrine for parenteral administration will be supplied in 1:1000
concentration: thus each milliliter will contain 1mg of the agent.
- Because of short duration of action of epinephrine, multiple
administrations maybe necessary during the acute phase of it.
- Unit dose (1ml) ampule are preferred over multiple dose vials
because the unit dose form will prevent the rescuer from inadvertently
administering an overdose.
- A little epinephrine may be life-saving but a lot may be lethal.
- It is used to start administration of epinephrine with 0.3 to 0.5 ml of
solution, I.m or Sc.
Suggested for emergency kit :
On preloaded syringe [1ml of 1:1000 (1mg epinephrine)] and three to
four ampules of 1:1000 epinephrine.
Action: -adrenergic agonist with some - effects.
11
PHARMACOLOGY
Epinephrine is an endogenous catecholamine
Epinephrine is a direct-acting sympathomimetic agent that exerts its effects
on both and -adrenoceptors.
Clinical pharmacology:
- Parenteral administration of epinephrine produces hemodynamic
metabolic and electrocardiographic effects.
- Rapid intravenous injection produces rapid rises in systolic and
diastolic blood pressure.
- Slow IV or subcutaneous injection, however produces a moderate
increase in systolic BP and drop in diastolic BP caused by a
predominantly B2 stimulant vasodilator effect or blood vessels in
skeletal muscle.
- In infusion produces hypokalemia.
Pharmacokinetics
- Pharmacologically active concentrations of epinephrine are not
achieved following oral administration as it is rapidly oxidized and
conjugated in the gastrointestinal mucosa and liver.
- Absorption from subcutaneous tissue is slow because of local
vasoconstriction : effects are produced within 5 min.
- Absorption is more rapid after I.m than after subcutaneous injection.
- Epinephrine is rapidly metabolized in the liver, neuronal tissues and
else where.
- Upto 91% of IV dose is excreted in urine.
12
Metabolism :
Rapidly metabolized by oxidation de-amination and O-methylation,
catalyzed by enzymes monoamine oxidase and catechol-O-methyl
transferase respectively.
Therapeutic use :
1) TT of acute allergic reactions.
2) Emergency ft of life-threatening angioedema and anaphylactic shock.
3) Adjunctive use in management of cardiac arrest
4) Open-angle glaucoma.
Mode of use :
- Route of administration and dose vary with the indication and the
severity of condition.
- Repeated doses may be given in life threatening situations but dosing
more frequently than every 5 min is associated with higher incidence
of side effects and caution is susceptible patients.
Indications :
1) Acute allergic reactions :
Acute allergic reactions with airways obstruction should be treated
with 200 to 5mg epinephrine by SC or IM injection.
- This may repeated at internals of 15 to 30 min. depending on
response.
- SC should be preferred
2) Life threatening angioedema and anaphylactic shock :
- 1st line of treatment in these medical emergencies, mode of action of
epinephrine is not entirely clear but it is likely that its -agonist
13
14
worsen
angle
closure
glaucoma
and
epinephrine
is
and hepatocellular
vasoconstriction.
- In skeletal muscle vasculature epinephrine principally stimulation 2
receptors producing vasodilation.
- The net effect of these peripheral vasculature changes is preferential
distribution of cardiac output to skeletal muscles and decreased
systemic vascular resistance.
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17
18
CHLORPHENIRAMINE (MALEATE)
Belongs to the alkylamine group of classic H1 Histamines.
Pharmacology :
It clinically most relevant effect is on the smooth muscle of the
vascular the where it blocks histamine-induced increased capillary
permeability, and incompletely prevents the histamine-induced fall in
the blood pressure.
Clinical pharmacology :
Like other H1 antihistamines, chlorpheniramine antagonizes various
physiological and pathophysiological effects of histamine including
increased capillary permeability and dilatation the formation of edema,
the flare and itch response, and the constriction of gastrointestinal
and respiratory smooth muscle.
Acute overdose :
When taken in excessive doses the intoxicated patient is unconscious
and shows hypertension, coma, and occasionally, convulsions which
are difficult to it.
DIPHENHYDRAMINE
- is a H1 histamine receptor antagonist.
Clinical pharmacology :
- Histamine is found in high concentrations in most cells in skin, lung
and intestinal mucosa.
- Its actions at H1 sites include contraction of bronchial intestinal and
vascular smooth muscle, but relaxation of smooth muscle in blood
vessels.
19
20
Side effects :
Major side effect of diazepam is respiratory depression or arrest,
however careful titration during administration this is unlikely to occur.
Availability :
Diazepam (valium)
NARCOTIC ANTAGONIST :
Drug of choice : Naloxone (Narcan)
Alternative drug : nalbuphine (Nubain)
- If a narcotic analgesic or pentazoline is used for psychosedation
techniques, a narcotic antagonist must be readily available.
- Narcotic antagonist are indicated for reversal of narcotic depression,
including respiratory depression.
Side effects : Contraindications : precautions
The duration of naloxone is short quite possibly shorter than that of
the narcotic it is reversing. This situation may lead to recurrence of
respiratory depression following a period of apparent recovery.
For this reason all patients receiving naloxone must be observed for at
least 1 hour after its administration.
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Mode Of Use
- Naloxone can be administered by IV, IM or SC in opioid over dose,
5-10 mg. kg is the used initial IV dose and may be repeated at 2-3
min intervals until the desired response is seen.
- At least 2mg should be used to constitute an adequate trial in
overdose of unknown cause.
- The duration of action of long acting opioids may outlast that of an
IV dose of naloxone so patient should be carefully monitored for
signs of returning opioid depression.
- Iv infusions have been employed to avoid this problem commencing
at 2-5 mg. kg hourly and adjusted act to response.
- Absorption is good from IM and SC sites but rate of onset is slower
than via the IV route.
Action:
Competitive antagonist at opioid receptors.
Antagonizes endogenous or exogenous opioids, reverses all effects such as
analgesia, respiratory depression, papillary constriction, coma and
convulsion.
NALOXONE (HYDROCHLORIDE)
Naloxone is the 1st opioid antagonist to be developed that is devoid of
agonist activity.
Indications :
1) Reversal of effects of opioid drugs.
2) Diagnosis and treatment of opioid addiction.
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25
VASOPRESSORS :
Drugs of choice methoxamine ( vasoxyl)
Alternative drug phenylephrine (Neo-symphrine)
- Vasopressors such as methoxamine (vasoxyl) and phenylephrine
(neo-synephrine) are drugs that produce moderate blood pressure
elevations through the mechanism of peripheral vasoconstrictions.
- Methoxamine is a clinically useful Vasopressor with, sustained action
and with little effect on the myocardium or CNS.
- Its vasopressor action is associated with marked increase in the
peripheral resistance and no increase in cardiac output. A
compensatory bradycardia accompanies the rise in BP.
- Onset of the vasopressor action is almost immediate following IV
administration and may persist for upto 60 min.
Therapeutic indications :
- Management of hypotension, in which the state of the heart is
unknown and the intent is to raise the blood pressure without cardiac
stimulation.
- Possible uses are in syncopal reactions, drug over dose reaction, post
seizure states, acute adrenal insufficiency, allergy.
Side effects, contraindications, precautions :
- Parenteral administration of most vasopressor is contraindicated in
patient with high BP or ventricular tachycardia.
- Extreme caution in patient with hyperthyroidism, Bradycardia, partial
heart block, Myocardial disease or severe arthrosclerosis.
26
Availability :
- Methoxamine (vasoxyl), 10mg/ml, and 20mg/ml
91ml ampules and 10ml vials)
- Phenylephrine 10mg/ml (1ml ampule)
Suggested for emergency kit :
- Methoxamine 10mg/ml (2 or 3 1ml ampules)
- Phenylephrine 10mg / ml (2 or 3 ml ampules)
METHOXAMINE :
Methoxamine is a pure a1- adrenoceptor agonist used to treat
hypotension resulting form vasodilation.
Pharmacology :
It is a constrictor of vascular smooth muscle through its action upon
post synaptic -receptors.
Clinical pharmacology :
Methoxamine produces its effects by a direct -adrenoreceptor
stimulant action on both resistance and capacitance vessels. There is
resultant dose-related increase in systemic vascular resistance and
arterial blood pressure.
Bradycardia occurs as a result of increased vagal activity as a reflex
response to the vasopressor effects of methoxamine Bradycardia can be
abolished by atropine.
27
Contraindications :
1) Hyperthyroidism: High doses of methoxamine cause marked
increases in BP associated with severe bradycardia.
2) Severe hypertension : High doses of methoxamine cause marked
increases in BP associated with severe bradycardia.
3) Myocardial disease : The increase in systemic vascular resistance
28
is
naturally
occurring
corticosteroid
used
29
INDICATIONS :
1) Replacement therapy for adrenocortical failure or hypopituitarism.
2) Status asthamaticus.
3) Anaphylactic reaction.
4) Soft tissue or joint inflammation.
5) Congenital adrenal hyperplasia.
6) Apthous ulcer.
1) Replacement therapy for adrenocortical failure or hypopituitarism.
Acute adrenal failure is a medical emergency, and may follow abrupt
cessation of corticosteroid therapy. in chronic primary adrenal failure,
hydrocortisone is usually administered usually at a dose of 20-30 mg daily.
A common dose schedule is long hydrocortisone in morning and 10mg late
afternoon.
Apart from adequate IV saline and glucose fluid replacement IV
hydrocortisone as sodium succinate or phosphate derivative should be given
at a dose of 100 mg 8 hourly adrenal failure secondary to hypopituitarism is
treated as a chronic adrenal failure. Therapy is generally guided by the sense
of well being, alertness, postural changes in BP, weight and strength.
2) Status asthamaticus :
IV hydrocortisone succinate in doses of 100-200 mg every 6 hour is
usually administered.
3) Allergic and anaphylactic reactions :
Allergic and anaphylactic reactions manifest in a variety of ways
including has sever, urticaria, angioneurotic edema, and shock. Life
threatening reactions should be treated with large doses (100-500 mg every
30
of
metabolic
acidosis
33
occurring
during
anaerobic
ATROPINE SULPATE :
Atropine is a parasympatholytic drug that decreases vagal tone
through its vagolytic action, there by increasing the rate of discharge of the
sinoatrial node.
Indications :
Management of severe sinus bradycardia when accompanied by
symptomatic hypotension or hypotension that might impair coronary artery
blood flow.
Side effects : contraindications
Atropine administration is therefore not recommended when bradycardia
is not associated with hemodynamic compromise (hypotension)
Availability : Atropine 5 mg [ 5ml (0.1 mg / ml) reloaded syringe]
Suggested kit : one preloaded syringe
CALCIUM CHLORIDE (CaCl2) :
Indications : Cardiac arrest
Electro mechanical dissociation and
Ventricular asystole
Calcium chlorides is effective in profound cardiovascular collapse in which
an orderly electrical rhythm is associated with an ineffective ejection of
blood from the heart (electromechanical dissociation).
Side effects
- Rapid administration of CaCl2 can produce a severe sinus bradycardia
or sinus arrest is the heart is beating.
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4) Chloride depletion
Indications :
1) Cardiac arrest
Cardiac arrest is often associated with a systemic acidosis with both
respiratory and metabolic components. It was believed that this acidosis
exacerbated
electrolyte
disturbances,
antagonized
the
effects
of
other
acute
forms
of
metabolic
acidosis,
Na
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37
Cardiac Action
Atropine increases sinus rate, and sinoatrial and Av conduction.
Although it is generally believed that the usual therapeutic dose (0.4
1 mg, commonly 0.6 mg) causes tachycardia.
Atropine inhibits salivary secretion, producing a dry mouth and
difficulty in talking.
Indications:
I) BRADYARAYTHMIAS AND MYOCARDIAL INFARCTION
Atropine is the it of choice in the severe bradycardia and hypotension
or syncope associated with a hyperactive carotid sinus reflex and vagal over
activity (vaso vagal syndrome).
Atropine is also useful in severe bradycardia or temporary sinus arrest
occurs during cardiac investigation initial dose of 0.6 or 1.2 mg is sufficient.
Atropine may be of value in the it of Av conduction block caused by
excessive vagal tone after acute myocardial infarction; it may reduce the
degree of block.
Atropine should be given only when bradycardia is associated with
signs or symptoms of hypotension and hypoperfusion, conduction
disturbance or entopic arrhythmias.
2) ANESTHETIC PREMEDICATION : Inhibition of secretion. Atropine
is a long standing anesthetic premedication, used to reduce salivary and
tracheobronchial secretions caused by many inhaled anesthetics, especially
diethyl ether. It is less potent antisialogogue to than scopolamine but has
less prolonged action and less postoperative sedation and confusion.
The concomitant bronchodilator action of atropine may be a useful
bonus in anesthetic use.
Conventional dose 300 600 mg in adults
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Availability
VASODILATOR
Drug of choice : Nitro glycerin
Alternative drug : Amyl nitrite
Side effects of amyl nitrite are more intense which include flushing of
the
face
pounding
pulse
dizziness,
intense
headache
hypotension.
Availability:
Nitroglycerin tablets , 0.1, 0.3, 0.6 mg tablet nitroglycerin spray.
Nitrite vapuroles (yellow), 0.3 ml.
40
and
Emergency kit :
One spray bottle of nitroglycerin (0.4 mg)
NITROGLYCERIN
Indications
1) Relief of angina pectoris
2) Prophylaxis of angina pectoris
3) Management of angina pectoris
4) Management of acute cardiac pulmonary edema
5) Management of chromic heat failure
6) Management of acute myocardial infraction.
7) Management of postoperative hypertension.
Contraindications
1) Obstructive hypertrophic cardiomyopathy
2) Raised intracranial pressure.
3) Cardiac tamponade.
Relating contraindication
1) Glaucoma
2) Mitral value proplapse
Mode of Use
All the clinical use depends upon production of venous and arterial
dilatation and to some extent of dilatation of coronary arteries.
1) Relief of angina pectoris
Sublingual nitroglycerin is widely used for the relief of effort induced
and resting angina. It acts by reducing cardiac work. Effects are more
41
pronounced in the standing than in the supine position and may lead to
syncope if vasodilation is pronounced. It is preferable to take nitroglycerin
in sitting position.
Nitroglycerin sublingually in a dose of 0.3 0.4 mg and repeated
every 3 min until either the pain resolves or max of 4 to 5 tablets have been
taken.
2) Prophylaxis of angina pectoris
For prophylaxis of angina pectoris, sublingual nitroglycerin is very
effective but its duration of effect last only for a few min to max of half an
hour. Nitroglycerin ointment every 4 to 6 hr may be prescribed and effects
last for several hours.
Another alternative is buccal nitroglycerin in dose of 3 5 mg every
6 hr.
Nitroglycerin patches, although claimed to have 24 hrs efficacies,
have been shown to be ineffective for 24 h prophylaxis of angina pectoris.
3) Unstable angina
Intravenous nitroglycerin is a very effective dry for relief of chest
pain by myocardial ischemia dose of upto 200 mg min or higher have to be
used.
4) Management of CHF :
Nitroglycerin by reducing venous return, lowers elevated end
diastolic pressure in the right and left ventricles and improves myocardial
function. The cardiac output either does not change or increases.
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5) Management of hypertension
IV nitroglycerin lower raised arterial presence and effective in
selected group of patient.
Contraindications :
1) Obstructive hypertrophic cardiomyopathy
By causing vasodilatation nitroglycerin reduces venous return to heart
and increases left ventricular out flow obstruction.
2) Raised intracranial pressure
Should be avoided, or venodilatation may further increased already
raised intracranial pressure
3) Cardiac tamponade
Filling of the ventricles is impaired and nitroglycerin may further
reduce this and cause syncope.
4) Glaucoma
This is a relative contraindication of nitroglycerin as intraoculas
pressure may increase.
Acute over dosage
Include hypotension, tachycardia, warm flushed skin, headache,
palpitations and syncope.
SECONDARY NONINJECTABLE DRUGS
Drug of choice : Aromatic ammonia
- Aromatic ammonia is the agent of choice as a respiratory
stimulant for the emergency kit.
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depression
not
induced
by
narcotic
andgesies
vasodepressor syncope.
Side effects : contra indications ad precautions
Caution with person with chronic obstructive pulmonary disease
(OPD) or asthma because it may precipitate bronchospasm resulting from its
irritating effects on the mucous membranes of the upper respiratory tract.
Availability : Silver gray vaporole (0.3 ml aromatic ammonia)
Suggested for emergency kit :
12 vaporoles
next to O2, aromatic ammonia is the most commonly used drug in
emergency kit.
ANTIHYPOGLYCEMIC (ORAL)
Agent of choice carbohydrate
Antihypoglycemic agents will be useful in the management of
hypoglycemic reactions occurring in patient with diabetes mellitus or in the
non diabetic patient with hypoglycemia.
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Therapeutic Indications
Hypoglycemic state secondary to diabetes mellitus or forting
hypoglycemia (in conscious patient)
Slide Effects : Contraindications : Precautions
No side effects
agents.
Metraproterenol
specific
beta
Therapeutic Indications
Metraproterenol,
epinephrine,
isoproteronol
has
potential
Availability :
Metraproterenol inhaler (alupent) :
Epinephrine mistometer (medihales epi)
Isoproterenol mistometer (mediholar 750)
46
EMERGENCY DRUGS
I. Cardiovascular emergencies drugs used
1) Acute myocardial infarction
Aspirin therapy
Nitroglycerine
Analgesics morphine sulphate
Streptokinase
2) Unstable angina
Aspirin
Nitrates
-blockers
3) Congestive heart failure
Vasodilators
Sodium nitroprusside
Digitalis
4) Hypertensive crisis
Nifedipine
Sodium nitroprusside
Nitroglycerine
Labetolol
Nicardipine
Esmolol
5) Shock
Fluid resuscitation
Vasopressors and inotropes
47
Dopamine
Dobutamine
6) Malignant hyperthermia
II. Respiratory :
1) Bronchial asthma :
O2
Bronchodilators
Epinephrine
Systemic corticosteroids
2) Acute respiratory failure :
Bronchodilators
Corticosteroids
III. Neurological emergencies :
1) Status epilepticus Anticonvulsant
Diazepam
Phenytoin
Phenobarbital
2) Stroke : transient ischemic attack
Antiplatelet therapy
Anticoagulant therapy
Heparin and Warfarin
IV. Endocrine emergencies
1) Thyroid crisis :
48
49
50
2) NITROGLYCERINE : VASODILATOR
Nitrates cause vascular smooth muscle relaxation by conversion to
nitric oxide.
This dilatation is more marked on the venous than the arterial side of
the circulation, so that myocardial preload is reduced proportionately more
than after load.
- Nitrates also dilate the coronary arteries, relieving spasm and
redistributing flow from epicardial to endocardial regions by opening
up collateral channels.
- Nitroglycerin sublingually in a dose of 0.3-0.4 mg and repeated every
3 min.
- Nitroglycerin acts in 1 to 2 min when placed sublingually.
Side effects : contraindications : precautions
Transient pulsating headache
Facial flushing
Contraindicated in hypotensive patients
Nitroglycerin also available in spray bottles.
3) ANALGESICS :
It is hear that the pain of AMJ is due to continuing ischemia of living
jeopardized myocardium rather than to the effects of completed myocardial
necrosis.
Morphine sulfate and pethidine hydrochloride are the two traditional
drugs used to control ischemic pain.
Used dose is 10-15 mg morphine
If pain very intense IV in a dose of 2-5mg to be repeated 10-15 min
half the dosage,
51
52
53
without
causing
reflex
55
tachycardia
(thus
lowering
ACE
inhibitors
not
only
relieve
symptoms
and
improve
hemodynamic profile, but have also (the only drug) been found to improve
survival especially in cases with moderate and severe chronic HF.
TT may be started with any ACE inhibitor but in cases with
borderline BP, especially when on diuretic therapy, captopril or enalapril
may be safer because of their shorter duration of action.
Initial dose should be small (captopril 6.25mg; enalapril 2.5mg),
patient closely observed, and if there is no unusual drop in BP the next dose
may be doubled.
ACE inhibitors are generally safe, the only hazard being excessive
hypotension.
All ACE inhibitors are contraindicated in patients with intrinsic rend
disease, systemic hypotension.
Digitalis :
Digoxin : This should be used as first line therapy in patient with failure and
atrial fibrillation when it will usually provide adequate control of the
ventricular rate together with a small positive inotropic effect.
In emergency situation, 0.5 mg out of the total calculated dose should
be given IV slowly over 5-10 min and remaining by oral route over next 24
hours (rapid digitalization).
Digoxin toxicity :
- Gastrointestinal Anorexia, nausea, vomiting
- SVS bradycardia, ectopic beats.
- Miscellaneous fatigue, headache, confusion, hallucination.
Diuretics :
Diuretics in one form or the other are always used in HF whenever
there is evidence of fluid retention.
56
57
59
60
and
hence
are
likely
to
worsen
myocardial
ischemia.
and
muscular
rigidity
characterize
malignant
hyperthermia syndrome.
- Serums creative kinase is markedly elevated.
- Multiple
genetic
mutations
are
associated
with
malignant
63
64
65
67
1) ANTIPLATELET THERAPY
Aspirin is now universally accepted as the most effective drug
available to prevent TIAs as well as to reduce the incidence of subsequent
stroke. It has been shown that Aspirin produces a rapid antithrombotic effect
by inhibiting cyclooxygenase and blocking formation of thromboxane A 2 in
platelets almost instantly, when given in small doses than in large doses. A
common dose is 325 mg/day.
The combination of aspirin (25mg bid) and extended release dipyridamole
(200mg bid) may be more effective in stroke prevention after TIA.
Dipyridamole is a vasodilator that in combination with aspiration reduces
thrombosis in patient with thrombotic disease.
8.
Patient
who
TILOPIDINE.
cannot
This
tolerate
newer
aspirin
antiplatelet
should
agent
be
prescribed
prevents
platelet
Propranolol 1-3 mg given slow IV and repeated 1mg after 3-4 hours.
During this patient should be loosely observed for pulmonary edema,
bronchospasm.
3) CORTICOSTERIODS : Since biological half-life of cortisol is
sheltered and adrenocortical reserve is reduced in thyrotoxic crisis, large
doses of corticosteroids should be given
E.g. Hydrocortisone 200 mg IV initially, forward by 100 mg every 6
hours.
ACUTE ADRENAL INSUFFICIENCY :
- Key element in it is speed of action, replenishment of intravascular volume
and administration of corticosteroids.
1) Volume replacement :
Severe volume depletion, hyponatremia and hypoglycemia invariably
exist together in acute adrenal insufficiency. The fluid deficit often exceeds
6% of body weight. 5% dextrose in normal saline is fluid of choice and
should be infused at an initial rate of 500-1000 ml/hr. therapy guided by
hourly record of pulse, BP.
2) Corticosteroids : Hydrocortisone provides the best steroid replacement
as it contains both glucocorticoid and mineralocorticoid activity. An initial
dose of 200mg IV over 3-5 min should be followed by 100mg (1.5mg/kg)
every 6 hours. IV should be continued for 24 hours after recovery from
adrenal crisis. Thereafter prednisolone in daily dose of 20-40 mg.
3) Other measures : If hypotension vasopressors such as Dopamine.
MYXEDEMA CRISIS :
70
SYNCOPE :
10.Trendelenburg position and 100% O2.
11.Spirit of ammonia may be placed under right nose. This noxious odor
stimulates the respiratory and vasomotor centers of the medulla.
HYPOGLYCEMIA :
1) Autonomic (or neurogenic) symptoms : Include sweating,
palpitation, and hunger. Increased secretion of counter-regulatory
hormones (e.g. Epinephrine) account for these symptoms.
2) Neuroglycopenic symptoms : develop as blood glucose decreases
further include impaired concentration, irritability, blurred vision,
lethargy, and development of Seizure or lama.
TT:
1) Readily absorbable carbohydrates : (e.g. Glucose, and sugar
containing beverages ) can be administered orally to conscious
patients for rapid effect. Hypoglycemia associated with a carbose or
miglitol therapy should be preferentially be treated with glucose,
because these -glucosidase inhibitors block the digestion of
disaccharides and complex carbohydrates.
2) IV Dextrose : Is indicated for severe hypoglycemia, in patients with
altered consciousness, and during restriction of oral intake. An initial
bolus 20-50 ml 50% dextrose, should be given immediately followed
by infusion of D5 to maintain blood glucose above 100 mg/dl.
3) Glucagon : 1mg / ml (or SC) is an effective initial therapy for severe
hypoglycemia in patients who are unable to maintain oral intake or in
whom on an IV access cannot be secured immediately.
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REFERENCES :
1. medical emergencies in the dental office,
Malamed
2. The pharmacological basis of therapeutics
Goodman and Gillmans
3. Essentials of Medical Pharmacology
K.D. Tripathi
4. Washington Manual of Medical Therapeutics
5. Pharmacology and Pharmacokinetics
Satoskar and Bandarkar
6. Principles and Practice of Medicine
Davidsons
7. Medical Emergencies in General Practice
SP Gupta and Dinesh K Gupta
8. Current Medical Diagnosis and Treatment
CMDT 2003.
9. OMSCNA- PHARMOCOLOGY- Vol 13, no. 1, Feb 2001.
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