Drugs in Emergencies

Dr U I Hapuarachchi
Department of Surgery Faculty of Medicine, Galle

Learning objectives
At the end of this lecture, you should be able to demonstrate;

Commonly used drugs Indications Routes of administration Common adverse effects

Content

Vasoconstrictors
Anti-arrhythmic drugs

Inotropes
Vasodilators

Opioid antagonists

Adrenaline

1 mg/ml 1:1000 concentration Brown colour ampoule

Mode of Action

& effects

Adrenaline
Indications

Cardiac arrest VF or Pulseless VT -iv Anaphylaxis im or iv Inotrope - iv Laryngospasm - nebulization Local infiltration with LA vasoconstrictor

Adrenaline
Dose

1:1000 im anaphylaxis 1:10000 iv Anaphylaxis & cardiac arrest 1:200000 infiltration 0.05-0.5 g/kg/min - infusion

Side effects

myocardial O2 consumption heart rate Pro arrhythmic

Vasopressin

20 iu/ml 1 ml clear ampoule

Mode of action

Smooth muscle V1 receptor stimulation Intense vasoconstriction

Indications

Septic shock resistant to other vasoconstrictors Variceal bleeding

Vasopressin
Dose

0.03 iu/min as an infusion in sepsis 20 iu over 15 min in variceal bleeding

Side effects

Headache Myocardial and peripheral ischaemia Nausea & vomiting

Amiodarone

150 mg/ml 2 ml ampoule Brown colour ampoule

Mode of Action

Membrane stabilizing anti-arrhythmic duration of action potential & refractory period Mild negative inotrope

blockage

Amiodarone
Indications

VF or pulseless VT cardiac arrest just before 4th shock Unstable tachycardia (narrow/broad complex) Stable broad complex tachycardia Stable narrow complex tachycardia

Amiodarone
Dose

300 mg bolus diluted in 20 ml of 5% Dextrose (unstable- 10-20 min, stable 20-60 min) 900 mg infusion over 24 hours

Side effects

Hypotension & bradycardia Prolonged use photosensitivity, abnormal thyroid

function, peripheral neuropathy, pulmonary fibrosis, hepatic dysfunction

Atropine

1 mg/ml or 0.6 mg/ml vial Clear colour ampoule

Mode of action

Blocks the parasympathetic neurotransmitter acetylcholine (anti-muscarinic)

Atropine
Indications

Cardiac arrest Asystole of PEA Bradycardia With neostigmine in reversal of muscle paralysis Antisialogogue

Atropine
Dose

0.5 mg iv 0.02 mg/kg in reversal

Side effects

Blurred vision, dry mouth Urine retention Acute confusion state

Adenosine

3 mg/ml vial 2 ml

Mode of action

Naturally occuring purine nucleoside transmission across AV node Extremely short half life 10-15 sec

Adenosine
Indications

Stable narrow complex tachycardia not terminated by vagal maneuvers Can be given in undiagnosed VT If SVT - ventricular rate If VT no change in ventricular rate

Adenosine
Dose

6 mg > 12 mg > 12 mg in SVT

Side effects

Negative inotrope hypotension Nausea, flushing Chest discomfort Bronchospasm

Verapamil

2.5 mg/ml 2 ml vial

Mode of action

Slows conduction / refractoriness in AV node

Indications

Stable narrow complex tachycardia not terminated by vagal maneuvers / adenosine Control of ventricular rate in patients with AF or Atrial flutter

Verapamil
Dose

2.5-5 mg iv over 2 min Repeat 5-10 mg every 15-30 min Maximum < 20 mg

Side effects

Headache, flushing Hypotension due to myocardial contractility

Digoxin

250 g/ml 2 ml vial

Mode of Action

vagal tone sympathetic activity by suppression of baroreceptors Prolong AV node refractory period

Digoxin
Indications

AF with fast ventricular rate

Side effects

Nausea, diarrhoea, anorexia Confusion, dizziness

Digoxin
Toxicity increased by

Hypokalaemia Hypomagnesaemia Hypoxia Hypercalcaemia Renal failure hypothyroidism

Dobutamine
Mode of Action

1, 2 effects

Indications

Inotrope of choice in post resuscitation Useful when pulmonary oedema is present

Dobutamine
Dose

5-20 g/kg/min as infusion

Side effects

Tachycardia Arrhythmias Exacerbate myocardial ischaemia

Noradrenaline
Mode of action

Potent agonist Mild effect

Indications

Severe hypotension with low peripheral vascular resistance Septic shock

Noradrenaline
Dose

0.05-0.5 g/kg/min as infusion

Side effects

Headache Bradycardia Arrhythmias Peripheral ischaemia

Dopamine

D1, D2, 1, 1 & 2 effects Dose 1-20 g/kg/min Renal dose Dopamine ? Indicated for hypotension in the absence of hypovolaemia May cause cardiac arrhythmias, myocardial O2 demand & worsen ischaemia

Naloxone

Used for opiate overdose Competitive antagonist at opioid receptors Reverses all effects of opioids Duration of action < opioids Need frequent boluses or infusion 400 g/ml 1 ml vial

Others

Calcium chloride Ephedrine Magnesium sulphate Sodium bicarbonate Beta adrenergic blockers Nitrates

References

Bennett PN, Brown MJ. Chapter 22- Adrenergic mechanisms & Drugs. Clinical Pharmacology- 9th Edition Pg 447-455 Bennett PN, Brown MJ. Chapter 24- Cardiac arrhythmias & Cardiac failure. Clinical Pharmacology- 9th Edition Pg 497-513 Richards D, Aronson J. Anti-arrhythmic drugs. Oxford Hand Book of Practical Drug Therapy Pg 77-103 Richards D, Aronson J. Adrenoceptor agonists & Anti-muscarinic Drugs. Oxford Hand Book of practical Drug Therapy Pg 190-199 http://www.resus.org.uk Guidelines, medical information & reports > Resuscitation Guidelines 2005 > Adult & paediatric Advanced life Support

Thank You