COMPREHENSIVE Flashcards
LIST the procedures for prescribing medications.
a. Prescription drugs- Require a written prescription by an accredited authorized prescriber provider. The prescription is a legal document that contains the
information required to dispense the medication. Some commands utilize computer order entry, the Composite Health Care System (CHCS) to process patient’s prescriptions and these substitute for a hand- written prescription. Faxed prescriptions are no longer authorized as per Chapter 21 of the MANMED.
b. Non-Prescription drugs-Commonly referred to as over-the-counter (OTC) drugs such as aspirin, antacids and cold remedies, which can be purchased anywhere without the services of a physician or pharmacist.
c. Authorized prescribers will use electronic order entry (CHCS), DOD prescription (DD 1289), or poly- prescription (NAVMED 6710/6). Controlled substances shall be
written only on the DD 1289, never on a poly-prescription. Prescriptions must be written in ink, indelible pencil or typewritten and must show the following:
(1) Patient’s full name.
(2) Date prescription written.
(3) Patient’s age or date of birth
(4) Full name of drug, form of drug, dosage size or strength written in the metric system, and quantity to be dispensed. Prescriptions should be written generically.
(5) Directions for the patient.
(6) Legible signature of the provider.
(7) Refill authorization.
d. Hospital Corpsman on independent duty are not required to use the DD1289 for prescribing drugs, other than controlled drugs, unless directed by the Commanding Officer or higher authority.
e. Not being required to fill out a DD1289 DOES NOT relinquish the IDC from other administrative responsibilities. Proper SOAP note documentation must be completed, including drug administered, quantity, and directions.
DESCRIBE the general principles of pharmacology.
a. General principles of pharmacology are:
(1) The factors that affect the actions of drugs.
(2) Factors that affect drug reactions.
(3) Various types of drug interactions.
(4) Factors influencing drug response interactions.
DESCRIBE the factors that affect the actions of drugs.
a. Pharmacokinetic: Activities of the drug after it enters the body. Pharmacokinetics is the study of drug absorption, distribution, metabolism, and excretion. A fundamental concept in pharmacokinetics is drug clearance, that is, elimination of drugs from the body
b. Absorption: The transfer of the drug from the body fluids to the tissues.
(1) Active absorption: Carrier molecule such as a protein or enzyme actively moves the drug across the membrane.
(2) Passive absorption: Diffuse across a membrane from area of higher concentration to an area of lower concentration (Water Soluble Drugs)
(3) Pinocytosis: Cells engulf the drug particle across the cell membrane. Think packman!
(4) Bioavailability is a subcategory of absorption. It is the percentage of the administered drug dose that reaches the systemic circulation. For drugs taken orally, bioavailability occurs only after the medication has been absorbed and metabolized by the liver. Oral drugs that have a first pass hepatic metabolism may only have a bioavailability of 20-40% as opposed to I.V medications that have a 100% bioavailability.
c. Factors that alter Bioavailability are:
(1) The drug from (e,g tablet, capsule, sustained release, liquid, trans-dermal patch,inhalation).
(2) Route of administration
(3) Changes in Liver metabolism caused by dysfunction.
(4) G I mucosa and motility.
(5) Food and drugs
(6) Solubility: Drugs that are fat soluble are absorbed faster than water-soluble drugs.
d. Distribution: Movement of drug throughout the body typically on proteins (albumin).
(1) Therapeutic effect: Drug levels in blood to produce desired effect.
(a) Too high = toxic
(b) Too low = decreased effect
e. Metabolism: Chemical reaction by with liver converts drug to inactive compound.
(1) Metabolism occurs in the Liver, Kidneys, lungs, plasma, and intestinal mucosa.
(2) A patient with liver disease may require a lower dose of a medication that is metabolized by the liver or a different medication that is not metabolized by the liver.
f. Excretion: Elimination of drugs from the body.
(1) Kidney excretes the inactive compounds from the body in the urine.
g. Half - Life: Time required for the body to eliminate 50% of the drug.
(1) Kidney, Liver disease and old age can increase the half-life increasing risk of toxicity.
h. Pharmacodynamic: Drug’s actions and effects within the body.
(1) Primary or desired effect.
(2) Secondary effects (side effects) – desired or undesired.
i. Physical dependence: A compulsive need to use a substance repeatedly to avoid mild to severe withdrawal symptoms.
j. Psychological dependence: A compulsion to use a substance to obtain a pleasurable experience.
k. Pharmacogenetic disorder: A genetically determined abnormal response to normal doses of a drug.
l. Receptor: A specialized macromolecule that binds to the drug molecule, altering the function of the cell and producing the therapeutic response.
m. Alterations in Cellular Environment: A drug that alters cellular function can increase or decrease the physiologic functions of the cell
Ex: Increased heart rate, decrease blood pressure.
(1) Therapeutic Response: Alteration of cell to achieve the desired response.
(2) Agonist: Drug that binds with a receptor to produce the therapeutic response.
n. Antagonist: Drug binds to receptor stronger than the agonist thus producing no pharmacologic effect Ex: Narcan is antagonist to morphine.
DESCRIBE the factors that affect drug reactions.
a. Adverse reaction: Undesirable drug effects.
b. Allergic reaction: A drug reaction that occurs because the individual’s immune system views the drug as a foreign substance.
c. Drug idiosyncrasy: Any unusual or abnormal reaction to a drug that a patient can have, that do not occur in the vast majority of patients taking the same drug.
d. Drug tolerance: A decreased response to a drug, requiring an increase in dosage to achieve the desired effect.
e. Cumulative drug effect: A drug effect that occurs when the body has not fully metabolized a dose of a drug before the next dose is given.
f. Toxic: A harmful drug effect if it is delivered in high dose or when blood concentration levels exceed therapeutic level (as seen in patients with Liver or Kidney disease).
(1) May be reversible or irreversible depending on organ/tissue damage. Liver has ability to regenerate but hearing loss may be irreversible due to streptomycin toxic reaction.
(2) You have to know the signs and symptoms of toxicity for drugs you are giving.
g. Pharmacogenetics Reactions: Inherited traits that cause abnormal metabolism of the drug. Ex: G6PD patient taking aspirin or sulfonamides will have hemolysis of their RBCs.
h. Pharmaceutic phase: The dissolution of a drug. Usually applying to the breakdown of tablets.
IDENTIFY the various types of drug interactions
a. Drug Interactions: When one drug interacts with or interferes with the action of another drug. Ex: Antacid with oral tetracycline decrease effectiveness of tetracycline.
b. Additive drug reaction: A reaction that occurs when the combined effect of two drugs is equal to the sum of each drug given alone.
c. Synergism: A drug interaction that occurs when drugs produce an effect that is greater than the sum of their separate actions.
d. Antagonist Drug Reaction: When one drug interferes with the action of another, causing neutralization or a decrease in the effect of one drug. Ex: Protamine sulfate completely neutralizes the effects of heparin.
e. Drug - Food Interactions: Drug given orally, food may impair or enhance its absorption. Ex: Proton Pump Inhibitor should be taken 1 hour before meals
DESCRIBE the factors influencing drug response.
a. Age: Immature or aging organ function affects metabolism of a drug.
Ex: Infants are less able to eliminate drugs in urine. The liver may produce more intense effects for longer periods.
b. Weight: Average weight is approximately 150 lb for both men and women. A medication may need to be increased or decreased.
c. Gender: Women require smaller dose due to differences in body fat and water ratio compared to men.
d. Disease: Liver disease may affect ability to metabolize or detoxify a drug.
e. Route of Administration: IV drug produce the most rapid response than any other method.
f. Drug Use and Pregnancy.
(1) Teratogen: A substance that may produce physical or functional defects in a human embryo or fetus.
PRACTICE dosage calculations.
a. The correct dosage must be established prior to administering or dispensing a medication.
b. The metric system is the officially used system of weights and measures used in the military.
The Avoirdupois and apothecary Systems are two other commonly used systems of measure.
(1) Basic units are as follows:
(a) Weight: Micrograms (mcg) or Milligrams (mg) Grams (g) Kilgrams (kg)
(b) Volume: Milliliter (ml) or Liter (l) Note: 1 Milliliter (ml) = 1 Cubic Centimeter (cc).
(c) Length: Meter or (m)
c. Frequently used unit conversion are done in three decimal places for convenience (the
thousandth or thousand). Here are some examples:
(1) 1 kilogram = 1000 grams
(2) 1 gram = 1000 milligrams
(3) 1 milligram = 1000 micrograms
d. Conversions
(1) It is often necessary to convert solution concentrations from liters to milliliters or drug
weights from grams to milligrams or micrograms.
(2) It is essential to understand the conversion process.
(3) If you are converting to a smaller unit of measure, you must move the decimal to the right.
If you are converting to a larger unit of measure, you must move the decimal to the left.
e. Ratios
(1) A ratio is defined as the relationship of one number to another.
(2) All percentages are ratios expressed as parts per hundred
DESCRIBE the routes of drug administration
a. The oral route is the most frequent route of drug administration and rarely causes
physical discomfort when taken properly. Oral drug forms include tablets,
capsules, and liquids. Oral medications may be administered via the following
methods:
(1) Nasogastric tube
(2) Buccal route: Drug is placed between the cheek and either the upper or
lower jaw and allowed to dissolve.
(3) Sublingual route: The drug is placed or sprayed under the tongue.
b. Parenteral drug administration means giving the drug by one of following routes:
(1) Subcutaneous: Abbreviated as (SC), a subcutaneous injection places the drug
into the tissues between the skin and the muscle. This method is absorbed
more slowly than IM injections.
(2) Intramuscular: Abbreviated as (IM), an intramuscular injection places the
medication directly into the muscle. The rich supply of blood vessels in the
muscle tissue allows the medication to be rapidly absorbed.
(3) Intravenous: Abbreviated as (IV), a drug administered this route is given
directly into the blood via a needle or catheter inserted into a vein. The drug action occurs almost immediately since there is a direct path to the drug
receptors.
(4) Intradermal: Abbreviated as (ID) route is typically used to administer
sensitivity tests, such as the tuberculin test. The needle is inserted at a 15-
degree angle, and the medication/agent is placed between the first and second
layers of the skin, allowing for a slow absorption.
c. Drugs may also be applied to the skin and mucus membranes using several routes:
(1) Topical- Drugs administered via the topical route are applied directly to
the skin. Topical drugs come in a variety of forms including creams,
ointments, sprays, liquids, suppositories, as well as ophthalmic and otic
forms.
(2) Transdermal- Drugs administered via the transdermal route are rapidly
absorbed from the skin and have systemic effects. The drug dose is implanted
on a small patch (similar to a bandage) the backing is removed, and the patch is
applied to the skin. This method maintains a relatively constant blood
concentration and reduces the possibility of toxicity.
(3) Inhalation - Drug droplets, vapors, and gas are administered through the mucus
membranes of the respiratory tract. The patient breathes the drug through a
face mask, nebulizer or an endotracheal tube. The drugs administered via
inhalation primarily have a local effect on the lungs.
IDENTIFY the pharmacological profile of Psychotherapeutics.
a. Class: Sedatives and Hypnotics: Sedative-hypnotics are a class of drugs that cause a
dose-dependent depression of the Central Nervous System function, inducing sedation,
sleep, and unconsciousness with increasing dose. Agents in this class of drugs include,
barbiturates, benzodiazepine and melatonin agonists.
b. Barbiturates:
(1) Action:
(a) Long-acting barbiturates sedative, and hypnotic, have anticonvulsant properties.
Barbiturates depress the sensory cortex, decrease motor activity, alter cerebellar
function, and produce drowsiness, sedation, and hypnosis. In high doses,
barbiturates exhibit anticonvulsant activity; barbiturates produce dose-dependent
respiratory depression.
(2) Use:
(a) Sedation: Used as a sedative
(b) Seizures: Management of generalized tonic-clonic, status epilepticus and partial
Seizures.
1) Note: Using it to treat insomnia is NOT recommended as long-term use is
associated with a risk of dependence.
(3) Adverse Effects:
(a) CNS: Somnolence
(b) Respiratory: Hypoventilation
(c) GI: Nausea
(d) CV: Bradycardia
(e) Other: Agitation, confusion, nightmares, lethargy, vomiting, diarrhea, and
hypotension
(4) Contraindication/Warning/Caution:
(a) Hypersensitivity to phenobarbital, barbiturates or any component of the
formulation; marked hepatic impairment; dyspnea or airway obstruction;
porphyria (manifest and latent); intra-arterial administration, subcutaneous
administration (not recommended); use in patients with a history of
sedative/hypnotic addiction; nephritic patients (large doses).
(5) Patient Management:
(a) Check vital signs and record
(b) Assess patient after giving medication for effect
(c) Patient Education: Abuse potential
(d) Natural Remedies: Melatonin
(6) Example:
(a) Phenobarbital
(b) Thiopental (no longer manufactured in the United States or Canada).
c. Class: Antianxiety Drugs
(1) Antianxiety drugs can be further subdivided into:
1) Benzodiazepines (for short term use only)
2) Non- Benzodiazepines.
(2) Action:
(a) Most benzodiazepines causes generalized CNS depression (Sedative-
Hypnotics). Benzodiazepines may produce tolerance with long-term use and
have potential for psychological or physical dependence. These agents have NO
analgesic properties.
(b) Benzo: Bind to specific benzodiazepine receptors in the GABA receptor
complex, which enhances the binding of this inhibitory neurotransmitter.
(c) Non-Benzo: Act on brain’s dopamine and serotonin receptors.
(3) Use:
(a) Antianxiety agents-used in the management of various forms of anxiety,
including generalized anxiety disorder (GAD).
(b) Some agents are more suitable for intermittent or short-term use
(benzodiazepines), while others are more useful long- term (buspirone,
doxepin(Tricyclics), fluoxetine(SSRI), paroxetine(SSRI), sertraline(SSRI),
venlafaxine(SNRI).
(4) Adverse Effects:
(a) Long term use of benzodiazepines: Withdrawal syndrome after as little as 4-6
weeks of therapy. Never discontinue abruptly decrease over 4-6 weeks.
1) BuSpar may have less abuse potential.
2) Symptoms of withdrawal: Fatigue, metallic taste, HA, numbness in
extremities, sweating, dry mouth.
(5) Contraindication/Warning/Caution:
(a) Should not be used in comatose patients or in those with pre- existing CNS
depression. Should not be used in patients with uncontrolled severe pain. Avoid
use during pregnancy or lactation.
(b) Acute narrow-angle glaucoma
(c) Pregnancy class: D; Not recommended for use during pregnancy.
(d) Caution with impaired liver or kidney function.
(e) BuSpar and Zolpidem are Pregnancy Class: B
(f) Not to be taken with Alcohol, tricyclic antidepressants, and other antipsychotics.
(6) Patient Management:
(a) Use caution in older patient due to slow excretion.
(b) Benzodiazepines are used primarily in acute situations.
(c) Patient should lie down at least 30 minutes after taking benzodiazepines.
(d) May be taken with or without food or meals.
(7) Examples:
(a) Benzodiazepines (higher risk of dependency when used long term)
1) Alprazolam: Xanax
2) Diazepam: Valium
3) Lorazepam: Ativan
(b) Non- Benzo (Low risk of dependency).
1) Buspirone hydrochloride: Bu Spar
2) Hydroxyzine: Atarax
3) Sertraline (SSRI): May be used long term.
d. Class: Antidepressants
(1) Class:
(a) Tricyclic antidepressants (TCAs)
(b) Monoamine Oxidase Inhibitors (MAOI)
(c) Selective Serotonin Reuptake Inhibitors (SSRI)
(d) Serotonin-norepinephrine reuptake inhibitors (SNRIs)
(e) Serotonin Reuptake inhibitor/Antagonist
(f) Dopamine/Norepinephrine-Reuptake Inhibitor
(2) Action:
(a) TCAs
(b) Increase levels of norepinephrine and serotonin by inhibiting their reuptake, and
block the action of acetylcholine
(c) MAOI: Inhibits the activity of Monoamine oxidase resulting in increased
endogenous neuro-hormones.
(d) SSRI: Increase serotonin by inhibiting neuronal uptake to CNS.
(3) Use:
(a) Depressive symptoms, Anxiety (class dependent), Obsessive Compulsion
Disorder, Smoking cessation: (Bupriopion-wellbutrin)
(4) Adverse Effects:
(a) TCAs: Dry mouth, blurred vision, postural hypotension, urinary retention,
constipation, and orthostatic hypotension.
(b) MAOI: Food interactions, vertigo, nausea, constipation, dry mouth, headache,
and over-activity.
(c) SSRI: Nausea, vomiting (transient), sexual dysfunction, insomnia, and weight
gain.
(5) Contraindication/Warning/Caution:
(a) TCAs: Hypersensitivity to TCAs or any component of the formulation; coadministration
with or within 14 days of MAOIs; acute recovery phase
following myocardial infarction.
(b) MAOI: CVA disease, hypertension, CHF, and elderly.
(c) Wellbutrin (aminoketone class) is contraindicated in patients with a seizure
disorder or a predisposition to seizures, as it reduces the seizure threshold.
(d) SSRI: Fluoxetine is less effective in patients who smoke.
(6) Patient Management:
(a) May take 4-6 weeks to become effective.
(b) Do NOT stop abruptly.
(c) Do not take with St. Johns Wart.
1) St Johns Wart may be a natural remedy for depression.
2) Sertraline used with MAOI may result in a fatal reaction.
(7) Example:
(a) Tricyclic: Amitriptyline: Elavil
(b) MAOI: Nardil
(c) Serotonin Reuptake Inhibitor/Antagonist: Trazodone (Desyrel)
(d) Serotonin-norepinephrine reuptake inhibitors (SNRIs): Venlafaxine, Duloxetine
(e) Dopamine/Norepinephrine-Reuptake Inhibitor: Bupropion (Wellbutrin)
(aminoketone))- also commonly used in smoking cessation.
(f) SSRI: (First line medication for depression):
1) Citalopram: Celexa
2) Fluoxetine: Prozac
3) Sertraline: Zoloft
4) Paroxetine: Paxil
e. Class: Antipsychotic
(1) Action:
(a) Block dopamine receptors in the brain; also alter dopamine release and turnover.
Peripheral effects include anticholinergic properties and alpha-adrenergic
blockade.
(b) Antipsychotics are classified as “typical” (1st Generation) and “atypical” (2nd
Generation). Phenothiazine are known as “typical” anti-psychotics. Newer (2nd
Generation) are also known “atypical” agents and have fewer adverse reationa.
(c) Phenothiazine differ in their ability to produce sedation (greatest with
Chlorpromazine and Thioridazine), extrapyramidal (Parkinson-like reaction)
(greatest with Prochlorperazine and Trifluoperazine), and anticholinergic effects
(greatest with Chlorpromazine).
(2) Use:
(a) Treatment of acute and chronic psychoses, particularly when accompanied by
increased psychomotor activity. Use of Clozapine is limited to schizophrenia
unresponsive to conventional therapy. Selected agents are also used as
antihistamine or antiemetic. Chlorpromazine is also used in the treatment of
intractable hiccups.
(3) Adverse Effects:
(a) Anticholinergic: Dry mouth, hypotension, sedation, photophobia,
photosensitivity, and headache.
(b) Extrapyramidal: Parkinson like symptoms, Akathisia (extreme restlessness),
and Dystonia (Facial grimacing and twisting of the neck).
(c) Tardive dyskinesia: Irreversible, involuntary dyskinetic movements, rhythmic,
movements of the tongue face mouth or jaw. Tongue may protrude.
(d) Neuroleptic malignant syndrome: Mainly seen in Haloperidol (Haldol),
hyperthermia, rare but may progress rapidly over 24-72 hours. Immediately stop
medication, requires intensive symptomatic treatment.
(4) Contraindication/Warning/Caution:
(a) Not recommended for use in severely depressed patient.
(b) Hypotension
(5) Patient Management:
(a) Assess deviation from normal: Poor eye contact, failure to answer questions,
and monotone speech.
(6) Example:
(a) Haloperidol: Haldol (1st Generation)
(b) Prochlorperazine: Compazine (1st Generation)
(c) Quetiapine: Seroquel (2nd Generation)
(d) Olanzapine: Zyprexa (2nd Generation)
f. Class: CNS Stimulants
Amphetamines and Anorexiants
(1) Action:
(a) Produce CNS stimulation by increasing levels of neurotransmitters in the CNS.
Produce CNS and respiratory stimulation, dilated pupils, increased motor
activity and mental alertness, and a diminished sense of fatigue. In children with
ADHD these agents decrease restlessness and increase attention span.
(2) Use:
(a) The treatment of narcolepsy and as adjunctive treatment in the management of
attention deficit hyperactivity disorder (ADHD).
(3) Adverse Effects:
(a) Headache, dizziness, and apprehension
(b) Over stimulation of the CNS
(c) Insomnia, tachycardia, and blurred vision
(4) Contraindication/Warning/Caution:
(a) Moderate to severe, Hypertension, and stroke
(b) Glaucoma
(c) Hypersensitivity to Amphetamines:
1) Risk of physical dependence
(5) Patient Management:
(a) Take the drug in the morning 30-45 minutes before breakfast and before lunch.
(b) Insomnia and anorexia usually disappear during continued therapy.
(c) May be given on only school days.
(d) Do NOT increase the dose or take the drug more frequently.
(e) Decrease coffee or caffeine.
(6) Examples:
(a) Amphetamines
1) Methylphenidate HCL: Concerta
2) Dextroamphetamine: Adderall
(b) Anorexiants
1) Phentermine: Ionamin
IDENTIFY the pharmacological profile of Anticonvulsants
a. Class: Anticonvulsants
(1) Action:
(a) Reduction of excitability of the neurons of the brain.
(b) Types of seizures:
1) Psychomotor Seizure: May experience an aura with perceptual alterations,
and hallucination.
2) Tonic-clonic: Alternate contraction and relaxation of muscles.
3) Myoclonic seizures: Sudden, forceful contraction involving the musculature
of the trunk, neck and extremities
4) Absence seizures: (petit mal) brief loss of consciousness during which
physical activity ceases. Usually seen is children only and remits by early
puberty in most patients without major sequelae.
5) Epilepsy: Permanent, and recurrent seizure disorder
(2) Use:
(a) Decrease the incidence and severity of seizures of various etiologies. Some
anticonvulsants are used parenterally in the immediate treatment of seizures. It is
not uncommon for patients to require more than one anticonvulsant to control
seizures on a long-term basis. Many regimens are evaluated with serum level
monitoring. Several anticonvulsants also are used to treat neuropathic pain &
headache syndromes.
(3) Adverse Effects:
(a) Nausea, vomiting, constipation, bradycardia, hypoventilations, agitation,
bleeding, fever, and sore throat.
(b) Steven-Johnson (considered a medical emergency): Skin rash, pruritic,
exfoliative, and bullous.
(4) Contraindication/Warning/Caution:
(a) In patients with CNS depression (drowsiness & lethargy).
(b) Not recommended for use in pregnancy (Pregnancy (D)).
(c) Psychoses, acute narrow-angle glaucoma
(5) Patient Management:
(a) Do not miss a dose
(b) Regular serum plasma levels of the anticonvulsant.
(c) Avoid alcohol consumption.
(d) For an acute seizure you will use a benzodiazepine treat all patients with
generalized convulsive status epilepticus (GCSE). GCSE is operationally
defined as ≥ 5 minutes of continuous seizure activity, or more than one seizure
without recovery in between.
(6) Examples:
(a) Benzodiazepines to treat status epilepticus: Treatment of status epilepticus outof-
hospital appears to be safe and effective. Lorazepam 4 mg IV and midazolam
10 mg intramuscular (IM) are the best-studied drugs in this setting.
1) Diazepam: (IV) Valium
2) Lorazepam: (0.1mg/kg IV) Ativan
3) Midazolam: (IM) Versed
4) Clonazepam: (IV) Klonopin
(b) Phenytoin: (IV/TAB) Dilatin
(c) Ethosuximide: Zarontin
(d) Valproic acid: Depakote
IDENTIFY the pharmacological profile of Antiemetics/Antinauseants
a. Class: Anti-emetic
(1) Action:
(a) Phenothiazines act on the chemoreceptor trigger zone to inhibit nausea and
vomiting. Dimenhydrinate, Scopolamine, and Meclizine act as antiemetic
mainly by diminishing motion sickness. Metoclopramide decreases nausea and
vomiting by its effects on gastric emptying. Ondansetron block the effects of
serotonin at 5-HT3 receptor sites.
(b) Primarily by inhibiting the chemoreceptor trigger zone or by depressing the
sensitivity of the vestibular apparatus of the inner ear.
(2) Use:
(a) Antiemetic: Prophylaxis or treatment of nausea or vomiting.
(b) Antivertigo: Treatment of vertigo
(3) Adverse Effects:
(a) Drowsiness
(4) Contraindication/Warning/Caution:
(a) Not recommended for use in patients who are in severe CNS depression.
(b) Not recommended for pregnant patients (Pregnancy (X)).
(c) Do not use with alcohol.
(d) Will make sedation worse.
(5) Patient Management:
(a) Consider fluid replacement if repeated vomiting.
(b) Use Phenothiazines cautiously in children who may have viral illnesses. Choose
agents carefully in pregnant patients (no agents are approved for safe use).
(6) Examples:
(a) Antiemetics:
1) Phenothiazines:
a) Prochlorperazine: Compazine
b) Chlorpromazine: Thorazine
2) Metoclopramide: Reglan
3) Ondansetron: Zofran
4) Prochlorperazine: Compazine
5) Pomethazine: Phenergan
(7) Antivertigo
(a) Meclizine (antivertigo): Antivert
(b) Diphenhydramine: Benadryl
(c) Benzodiazepines: Ativan, Valium
IDENTIFY the pharmacological profile of Anesthetics
a. Class: Anesthetic
Note: Anesthetic removes the feeling or sensation (chemical changes to the nerve
impulse). Analgesic alleviates or relieves the pain from a patient.
(1) Action:
(a) Local anesthetics: Produce a local anesthesia by inhibiting transport of ions
across neuronal membranes, thereby preventing initiation and conduction of
normal nerve impulses. Combination of two anesthetics is applied as a system
consisting of a cream under an occlusive dressing. Active drug is released into
the dermal and epidermal skin layers, resulting in accumulation of local
anesthetic in the regions of dermal pain receptors and nerve endings.
(b) Ketamine: A non-competitive antagonist of glutamate at the N-methyl-Daspartate
(NMDA) receptor-cation channel complex, causing neuro-inhibition
and anesthesia, where the patient is dissociated from the surrounding.
(c) Ketamine may be selected to induce anesthesia in hypotensive patients or those
likely to develop hypotension during induction due to hypovolemia,
hemorrhage, sepsis, or severe cardiovascular compromise. Katemine typically
increases blood pressure (BP), heart rate (HR), and cardiac output (CO) by
increasing sympathetic tone.
(d) Also, ketamine excites opioid receptors within the insular cortex, putamen, and
thalamus, thereby producing analgesia.
(e) Low (sub-anesthetic) doses of ketamine produce analgesia, and modulate central
sensitization, hyperalgesia and opioid tolerance. Reduces polysynaptic spinal
reflexes.
1) IM: Anesthetic effect: 3 to 4 minutes
(2) Use:
(a) Local anesthetics are utilized to produce a loss of sensation prior to minor
painful procedures including: Insertion of cannula or needles,
Arterial/venous/lumbar puncture, Intramuscular injections, Subcutaneous
injections, Dermal procedures, Laser treatments, Circumcision. May be applied
to genital mucous membranes in preparation for superficial minor surgery.
(b) Induction of General or Regional Anesthetic
(3) Adverse Reaction- Ketamine:
(a) Ketamine: In patient with ischemic heart disease, sympathomimetic effects that
increase HR and BP may be detrimental due to imbalance between myocardial
oxygen supply and demand.
(b) Prolonged emergence from anesthesia (12%; includes confusion, delirium,
dreamlike state, excitement, hallucinations, irrational behavior, vivid imagery).
(4) Contraindication/Warning/Caution:
(a) Hypersensitivity to ketamine or any component of the formulation.
(b) Ketamine: Conditions in which increase in blood pressure would behazardous.
(c) When used for procedural sedation and analgesia: Known or suspected
schizophrenia (even if currently stable or controlled with medications).
1) Warning and Precautions: Experienced personnel: Use requires careful
patient monitoring, should only be used by experienced personnel who are
not actively engaged in the procedure or surgery. If used in a non-intubated
and/or non-mechanically ventilated patient, qualified personnel and
appropriate equipment for rapid institution of respiratory and/or
cardiovascular support must be immediately available. Use to induce
moderate (conscious) sedation in patients warrants monitoring equivalent to
that seen with deep anesthesia. Consult local regulations and individual
institutional policies and procedures.
2) The use of ketamine increases the risk of laryngospasm. Patients with a
history of airway instability, tracheal surgery, or tracheal stenosis may be at
a higher risk of airway complications.
(5) Patient Management:
(a) Advise patient on risk and benefits
(b) Assess allergies
(c) Advise of pain from injection
(d) Ketamine: Heart rate, blood pressure, respiratory rate, transcutaneous O²
saturation, emergence reactions; cardiac function should be continuously
monitored in patients with increased blood pressure or cardiac decompensation.
(e) Ketamine given at doses of 10-20 mg IV are used for analgesia, where a dose of
1- 2 mg/kg IV is given for induction of anesthesia and will need to manage
airway at that point. The IM induction of anesthesia dose is 4 to 6 mg/kg.
(f) If giving Ketamine IM for pain control, then give 20-40 mg IM.
(6) Example:
(a) Lidocaine: Xylocaine (Local anesthesia)
(b) Bupivacaine: Marcaine (Local anesthesia)
(c) Ketamine: Ketalar (Induction of general anesthesia)
(d) Propofol: Is the intravenous (IV) induction drug of choice for most non-trauma
patients because of its rapid onset and recovery, beneficial antiemetic and other
properties, and relatively benign adverse side effects. Rapid onset (30 to 45
seconds) and recovery.
(e) Etomidate: Is often selected to induce general anesthesia in patients with
hemodynamic instability due to any cause because it has rapid onset without
changes in blood pressure (BP), cardiac output (CO), or heart rate (HR). It is the
most hemodynamically neutral of the sedative-hypnotic agents used for
induction of general anesthesia.
IDENTIFY the pharmacological profile of non-narcotic Analgesics/Antiinflammatory/
Antipyretics.
a. Class: Analgesics
(1) Classes:
(a) Salicylate
(b) Non-salicylate
(c) Nonsteroidal Anti-inflammatory Drugs (NSAIDS)
(d) Urinary Analgesics
b. Class: Salicylates
(1) Action:
(a) Inhibition of prostaglandins, dilates peripheral blood vessels (cools body),
prolong bleeding by inhibiting aggregation of platelets.
(2) Use:
(a) Relief of mild to moderate pain
(b) Reduction of body temperature
(c) Inflammatory conditions
(d) Decrease risk of myocardial infarction
(e) Prevention and treatment of blood clots.
(3) Adverse Effects:
(a) Gastric upset, heartburn, nausea, vomiting, anorexia, and gastrointestinal
bleeding.
(b) May cause Reye Syndrome in children with chickenpox or influenza.
(4) Contraindication/Warning/Caution:
(a) Not recommended for use during pregnancy (Pregnancy (Cat D)).
(b) Not recommended for use in patients with bleeding disorders.
(5) Examples:
(a) Aspirin: Bayer, Ecotrin, Enteric coated Aspirin
c. Class: Non-salicylate
(1) Action:
(a) Analgesic and antipyretic
(2) Use:
(a) Relieve mild to moderate pain
(b) Reduce body temperature (antipyretic)
(c) Arthritis
(3) Adverse Effects:
(a) Urticaria
(b) Hemolytic anemia
(c) Hepatotoxicity
(d) Hypersensitivity to acetaminophen or any component of the formulation.
(e) Severe hepatic impairment or severe active liver disease.
(f) OTC labeling: When used for self-medication, do not use with other drug
products containing acetaminophen or if allergic.
(4) Contraindication/Warning/Caution:
(a) Hepatotoxicity: Acetaminophen is associated with acute liver failure, at time
resulting in liver transplant and death. Hepatotoxicity is usually associated
with excessive acetaminophen intake and often involves more than one
product that contains acetaminophen. Do not exceeds the maximum
recommended daily dose (>4g daily in adults). In addition, chronic daily may
also result in liver damage in some patients.
(5) Patient Management:
(a) Tylenol may be administered orally without regard to food; may administer with
food to decrease possible GI upset.
(b) Mostly safe in pregnancy. (Pregnancy (CAT: B))
(c) Assess for alcohol use before prescribing Tylenol.
(6) Examples:
(a) Acetaminophen: Tylenol
(b) Benzocaine-Menthol: Cepacol
d. Class: Nonsteroidal Anti-inflammatory Drugs (NSAIDS)
(1) Action: Inhibit the action of the enzyme cyclooxygenase (COX-1 & COX-2
(Nonselective) or Cox 2 -Selective) which is responsible for prostaglandin
synthesis.
(a) Anti-inflammatory
(b) Analgesic
(c) Antipyretic
(2) Use:
(a) Arthritis
(b) Mild to moderate pain relief.
(c) Dysmenorrhea (painful menstruation)
(d) Fever reduction
(3) Adverse Effects:
(a) Gastrointestinal: Nausea, and vomiting
(b) FDA warning: Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase
your risk of heart attack or stroke.
(c) Celecoxib: Dyspepsia, and renal function
1) (Relative reduction in GI toxicity compared with nonselective NSAIDs)
(d) Ibuprofen: Due to effects on platelets and their role in clotting. Increased risk
with higher dose. FDA Warning: https://www.fda.gov/ForConsumers/Cons
(4) Contraindication/Warning/Caution:
(a) Celecoxib (COX-2 Selective) –> allergy to sulfonamides
(b) Ibuprofen (Non-Selective) –> peptic ulcer, GI bleed, and hypertension
(5) Patient Management:
(a) Stop if prolonged bleeding or dark stools.
(b) Long term use may lead to GI bleed. COX-2 Selective NSAIDS are preferred
for long term use to reduced the risk of GI bleed.
(c) Take with food or milk
(6) Examples:
(a) NSAIDS:
1) Ibuprofen: Motrin, Advil
2) Indomethacin: Indocin
3) Ketorolac: Toradol
4) Naproxen: Aleve, Naprosyn
5) Celecoxib (selective COX 2 inhibitor): Celebrex
6) Meloxicam (selective COX 2 inhibitor): Mobic
7) Note: Indomethacin is first line treatment for Gout.
8) Mobic is used for once a day dosing. Toradol is used for acute pain in the
clinic usually given IM at 30-60 mg.
e. Class Urinary Anesthetic/Analgesic
(1) Action: Pyridium is a topical bladder and urethral anesthetic and analgesic through
an unknown mechanism.
(2) Use: Is a bladder analgesic used to treat pain associated with a urinary tract
infection.
(3) Dose: Is 100 mg TID for 5 days as needed for dysuria.
(4) Adverse Effects:
(a) Pyridium is known to turn the patient’s urine a reddish-orange color that can
stain undergarments. Warn patients about these two changes.
(b) Headaches, dizziness
(c) Stomach cramps
(5) Contraindication/Warning/Caution:
(a) Allergy to Pyridium or renal insufficiency.
(b) Patient Management: Pregnancy B
(6) Examples:
(a) Phenazopyridine: Pyridium
IDENTIFY the pharmacological profile of Narcotic Analgesics and Antagonist.
a. Class: Narcotic Analgesics
(1) Action:
(a) Opioids bind to opiate receptors in the CNS, where they act as agonists of
endogenously occurring opioid peptides (endorphins). The result is alteration to
the perception of and response to pain.
(2) Use:
(a) Narcotic analgesics-short term management of moderate to severe pain.
(3) Adverse Effects:
(a) Respiratory Depression
(b) Light-headedness
(c) Constipation
(d) Nausea/vomiting
(4) Contraindication/Warning/Caution:
(a) Head injury or increased ICP
(b) Hypoxia
(c) Hepatic impairment
(5) Patient Management:
(a) Identify the level of pain
(b) Determine the effectiveness of the narcotic after administration.
(c) Advise of risk of constipation
(d) Advise of respiratory risk
(e) Avoid concomitant use of narcotics and benzodiazepines (antianxiety
medication) or other CNS depressants when possible.
1) Avoid concomitant use of narcotics and some antianxiety Herbal Remedies:
Passion Flower, Kava & St. John’s wort.
(6) Examples:
(a) Agonist:
(b) Codeine: Codeine
(c) Fentanyl: Sublimaze
(d) Hydromorphone: Dilaudid
(e) Methadone: Dolophine
(f) Morphine sulfate: MS Contin
(g) Oxycodone: OxyContin
(h) Hydrocodone: Norco, Lortab, and Vicodin
b. Class: Narcotic Antagonist
(1) Action:
(a) An opioid antagonist is a receptor antagonist that acts on opioid receptors.
Naloxone is a commonly used opioid antagonist drug which is competitive
antagonists that bind to the opioid receptors with higher affinity than agonists
but do not activate the receptors. This effectively blocks the receptor, preventing
the body from responding to opiates and endorphins.
(2) Use:
(a) Overdose of a Narcotic
(3) Adverse Effect:
(a) Acute opioid withdrawal: Administration of naloxone causes the release of
catecholamines which may precipitate acute withdrawal or unmask pain in those
who regularly take opioids. Symptoms of acute withdrawal in opioid-dependent
patients may include pain, tachycardia, hypertension, fever, sweating, abdominal
cramps, diarrhea, nausea, vomiting, agitation, and irritability.
(4) Contraindications/Warning/Caution:
(a) Hypersensitivity to naloxone or any component of the formulation. Use with
caution in patients with CAD, pregnant women, and opioid dependent patients.
(5) Patient Management:
(a) Vital Signs
(b) Monitor for respiratory depression
(c) Dependency side effect risk
(6) Example:
(a) Naloxone: Narcan
IDENTIFY the pharmacological profile of Antihistamines/Decongestants.
a. Class: Antihistamine
Histamine: Highest amount found in basophils (WBC) and mast cells. Produce
vasodilation of arterioles and increased permeability of capillaries and venule, which
allows fluid to escape into the surrounding tissue resulting in localized swelling. 1st
generation antihistamines have increase side effects such as drowsiness since they
cross the blood brain barrier. 2nd Generation antihistamines has fewer CNS side
effects.
(1) Actions:
(a) H¹ - antihistamines work by binding to histamine H¹ receptors in mast cells
smooth muscle, and endothelium in the body as well as in the in the brain. They
suppress the histamine-induced wheal response (swelling) and flare response
(vasodilation)
(2) Uses:
(a) H¹- antihistamines are used to treat allergic reactions (e.g., itching, runny nose,
and sneezing). In addition, they may be used to treat insomnia, motion sickness,
or vertigo caused by problems with the inner ear (Dimenhydrinate and
Meclizine), urticaria, and as adjunctive therapy in anaphylactic reactions and
angioedema. Topical and ophthalmic antihistamines may minimize systemic
side effects,
(b) H² - antihistamines bind to histamine H² receptors in the upper gastrointestinal
tract, primarily in the stomach. Antihistamines that target the histamine H² -
receptor are used to treat gastric acid conditions (e.g., peptic ulcers and acid
reflux). May also help with the relief of Parkinson-like reactions
(Diphenhydramine)
(3) Adverse Reaction:
(a) Anticholinergic effects: Drying effect may increase thickening of bronchial
secretions, dizziness, fatigue, hypotension, and headache.
(4) Contraindication/Warning/Caution:
(a) Some antihistamine are classified as pregnancy CAT D and C, may result in
jaundice, hyperreflexia extrapyramidal symptoms in infants whose mothers
received antihistamines (particularly promethazine).
(5) Patient Management:
(a) Give medication with food due to GI upset.
(b) Risk of injury due to drowsiness.
(c) Do not use with alcohol.
(d) The patient may have photosensitivity.
(6) Examples:
(a) 1st Generation Antihistamines
1) Diphenhydramine: Benadryl, Diphenhydramine may be used for the
treatment of allergic conditions in pregnant women when a first-generation
antihistamine is indicated (Pregnancy Cat: B).
2) Hydroxyzine: Atarax
3) Promethazine: Phenergan
(b) 2nd Generation Antihistamines
1) Cetirizine HCL: Zyrtec
2) Fexofenadine: Allegra
3) Loratadine: Claritin
b. Class: Decongestant
Reduce swelling of nasal passages
Enhance drainage of sinuses
(1) Action:
(a) The vast majority of decongestants act by enhancing norepinephrine
(noradrenaline) and epinephrine (adrenaline) or adrenergic activity by
stimulating the alpha-adrenergic receptors. This induces vasoconstriction of the
blood vessels in the nose, throat, and paranasal sinuses, which results in reduced
inflammation (swelling) and mucus formation in these areas.
(b) The active ingredients in most ingested decongestants are Pseudoephedrine or
Phenylephrine. Decongestant nasal sprays and eye drops often contain
Oxymetazoline and are used for topical decongestion. Pseudoephedrine acts
indirectly on the adrenergic receptor system, whereas phenylephrine and
Oxymetazoline are direct agonists.
(c) The effects are not limited to the nose, and these medicines may cause
hypertension (high blood pressure) through vasoconstriction. But most
decongestants are not pronounced stimulants due to lack of response from the
other adrenoceptors.
(d) Decongestants are normally paired with antihistamines to lessen this effect, but
the combination of both classes of drugs do not necessarily cancel the sideeffects
of each other.
(2) Use:
(a) Common cold, hay fever or upper respiratory allergies, sinuses congestion, and
pressure.
(3) Adverse Effects:
(a) Sleeplessness, anxiety, dizziness, excitability, and nervousness. Topical nasal or
ophthalmic decongestants quickly develop tachyphylaxis thus long-term use is
not recommended, since these agents lose effectiveness after a few days.
(4) Contraindication/Warning/Caution:
(a) Use with caution in hypertension, DMII, and increased intraocular pressure.
(b) May worsen prostatic hyperplasia/urinary obstruction.
(c) Elderly may be more sensitive
(d) Pregnancy CAT C. Not recommended for use in pregnancy.
(5) Examples:
(a) Oxymetazoline HCL: Afrin (Notorious for causing rebound congestion when
used for more than 3 days consecutively).
(b) Pseudoephedrine: Sudafed
(c) Phenylephrine (Nasal/Ophthalmic Decongestant)
