ED/Surgery Meds Flashcards
How to adjust blood pressure in ED?
BP too high = Hydralazine
BP too low = Norepinephrine
How to adjust HR in ED?
HR too high = Cardizem
HR too low = Dopamine
How to adjust glucose in ED?
BG too high = Regular Insulin IV
BG too Low = D50 or D5 ½ NS IV
How to medically sedate an agitated patient?
B52 (Benadryl 25mg, Haldol 5mg, Ativan 2mg) IV
How to treat opioid overdose?
Naloxone (Narcan)
IV anti-inflammatory of choice in ED
Decadron IM, Solu-Medrol IV
How to treat fever in ED - baby vs adult?
Baby = Tylenol PR Adult = Toradol IV
How to treat vomiting in ED - baby vs adult?
Baby = Zofran liquid Adult = Zofran ODT, Phenergan PR
Common sedation meds for babies and adults
Baby = Versed nasally Adult = Propofol IV
How to treat emergency dyspnea?
DuoNeb SVN
Treatment for Croup
Racemic Epinephrine SVN
Antibiotic for common infections in children seen in ER
Bactroban Top, Amoxicillin PO, Omnicef PO
Go-to antibiotics for lungs
Azithromycin
Go-to antibiotics for GI infections
Cipro and Flagyl
Go-to antibiotic for most ENT infections
Amoxicillin, PCN for throat, Augmenting for sinuses
Antibiotics for mild, moderate, and severe UTI
Mild = Macrobid Moderate = Bactrim Severe = Cipro
Go-to antibiotics for skin infections
Keflex (+ Bactrim for MRSA)
What is a broad spectrum antibiotic good for empirical treatment of most infections?
Doxycycline
A 48 yo woman has difficulty breathing and a pulse ox of 88%. She smokes tobacco and has a history of childhood asthma but hasn’t had any issues for several years. What treatment should be given right away before further evaluation?
Albuterol + ipratropium
When choosing treatment for hypertensive emergencies, what characteristics of drug are most optimal?
Rapid onset
Short duration
Parenteral formulation
Modest potency (more gradual BP reduction)
What anti-HTN meds are most appropriate in HTN emergency?
Enalaprilat (ACE), Hydralazine, Labetalol (BB), Nicardipine (CCB), Nitropusside (vasodilator)
A 55 year old man had a lymph node biopsy last week which became infected and now he is septic. He is hypotensive despite IV fluids and there is a concern that he is in shock. He has no arrhythmias on EKG. Which med is most appropriate in treating his hypotension?
Norepinephrine
- Epi better for anaphylactic shock
Which type of insulin when given intravenously is most appropriate in bringing down the blood glucose in a patient with diabetic ketoacidosis?
IV short-acting like regular insulin
You are managing a patient’s glucose levels with insulin and now they have become hypoglycemic such that they have lost consciousness. You have IV access. What is most appropriate treatment?
hypertonic IV fluids - Dextrose (D50)
You are interviewing an intoxicated patient when they start speaking loudly and aggressively, pounding on walls, and throwing things. You decide to chemically restrain the patient. What med is both safe and effective?
Lorazepam
- B52 best for patient with acute/severe psychosis
Patient has become somnolent from too much Lorazepam. What can you give to wake him up?
Flumazenil (benzo receptor antagonist)
A 55 year old woman has claustrophobia and needs an MRI scan. Which med should be used for sedation?
Midazolam
- Ketamine also good but has more side effects
Best sedation to use for suturing 2 yo’s lip.
Midazolam
Midazolam vs Ketamine
Midazolam provides sedation but NO analgesia; Ketamine provides both
Ketamine commonly causes N/V and usually given with odansetron
Treatments for 30 yo woman in ED with a fever. IV and oral?
IV Ketorolac
Oral Tylenol or ibuprofen
A 25 year old patient is vomiting and is not able to tolerate any liquids. Which med is most appropriate?
odansetron
A 15 month old patient is vomiting and is not able to tolerate any liquids. He has acute gastroenteritis. Which med is most appropriate?
odansetron
What characteristics of dexamethasone make it an appealing therapy for acute inflammation?
- Long duration (36-48 hr)
- Rapid onset (3 hr)
- Fewer ADRs than other glucocorticoids
- High potency compared to hydrocortisone
- Oral similar onset and duration as parenteral
ABX for otitis media, uncomplicated UTIs in kids, CAP in kids, strep pharyngitis, sinusitis
oral amoxicillin
ABX for impetigo
Mupirocin
What can oral azithromycin treat?
OM, CAP, strep throat
alternative to PCNs or cephalosporins
What can oral Levofloxacin treat?
complicated and uncomplicated UTI
CAP
cellulitis or skin abscess
traveler’s diarrhea
Physiologic consequences of improperly treated acute pain?
CV: increased cardiac work, increased PVR and BP, MI
Pulm: tachypnea, decreased vital capacity, hypoxia, increased pulm infection risk
GI: reduced motility, ileus, N/V
Renal: urinary retention, oliguria
Coag: DVT, platelet aggregation
Others: impaired immune system, muscle atrophy, fatigue, depression, anxiety
Different opioid receptors and what effects they have?
Mu - “PEAR” = physical dependence, euphoria, analgesia, respiratory distress
Kappa - “SAM” = sedation, analgesia (spinal), miosis
Delta - “ARG” = analgesia, release of GH
Sigma - “Do HaRM” = dysphoria, hallucination, repiratory and vasomotor stimulation, mydriasis
What med is a full opioid agonist opioid?
Methadone
What med is full opioid antagonist?
Naloxone
Risk factors for PONV
female non-smoker dehydration Inadequate pain control h/o motion sickness h/o PONV GI or gyno surgery
ADRs of opioids
N/V constipation urinary retention orthostatic hypotension and bradycardia pruritus truncal rigidity
Principle agent used in PCA (patient controlled analgesia) devices
morphine
Receptors associated with central vomiting reflex and what meds antagonize these receptors
5HT-3/serotonin = ondansetron
Muscarinic/MI = scopolamine (anticholinergics)
histamine = dimenhydrinate
dopamine = promethazine
When should anticoagulants (like Warfarin) be stopped pre-op?
d/c 5 days prior to elective surgery (ie Tuesday before a Monday surgery)
Check PT/INR day before surgery; if INR >1.5 then consider administering a low dose of oral vitamin K (1-2 mg) and then recheck the following day
Restarting warfarin often needs a bridging approach - those with high risk of thromboembolism will need LMW heparin until warfarin “kicks in” again
What meds can be continued perioperatively?
anti-HTN
insulin
thyroid meds
aspirin controversial
Can ACE-inhibitors and diuretics be taken during surgery?
No, must be stopped day of surgery
Postpone elective surgery in patients who have glucose levels greater than _______.
300 mg (goal is under 200)
Indications of Midazolam (Versed)
Conscious sedation, anxiolysis, and amnesia during minor ED / surgical procedures, manipulations, or diagnostic procedures (including intubation)
Advantages of parental drug administration
Drugs can be administered to unconscious, uncooperative, or nauseous
Vastly decreases first-pass effect (skip liver)
Can be used to delay or slow onset of drug action
Disadvantages of parental drug administration
STRICT aseptic technique
Some degree of pain
Difficult to reverse drug effects
Inconvenient if freq dosing required
How is tourniquet appropriately applied?
Applied to upper arm
Pressure enough to block vein but not artery
What makes a good vein to put IV in?
bouncy - refills when depressed
easily palpable and visible
soft
above previous sites
Why do “bevel up” technique when doing IV?
insert bevel up at 10-30 deg angle
provides cutting action
reduces tissue damage
more
Complications of IV placement
Site infection: cellulitis, systemic bloodstream infection (emergency)
Infiltration/extravasation: isotonic fluids, alpha and beta adrenergic meds (emergency)
Phlebitis
Hematoma
Air embolism (emergency)
What injections use Z-technique?
IM injections; pull down skin to inject straight down, then let go of skin
What common meds are given SQ?
heparin, insulin
How to do SQ injections?
pinch large skin fold and “dart” needle into skin
3rd generation cephalosporin administered IV or IM
Cefriaxone
Indications for Lidocaine
V tach
Local anesthesia
Drug interactions of Lidocaine
CYP450
beta blockers
MOA of Lidocaine
Class IB anti-arrhythmic and cardiac depressant; weak Na channel blocker in Purkinje and ventricular cells and reduces AP
ADRs of opioids
GI upset, drowsiness, itching, constipation, respiratory depression, hyperalgesia, accident-proneness, tolerance, dependence, addiction/abuse
DIs of opioids
drugs that sedate
drugs that increase serotonin levels
hydrocodone + APAP =
Vicodin
Over medication of Midazolam can be reversed with _________.
flumazenil
MOA of Midazolam
Enhances GABA-dependent chloride conduction which hyperpolarizes the cell, inhibiting excitability (short acting 2-5 h)
ADRs of Midazolam
CNS depression (sedation, drowsiness, and much more), tolerance, dependence, respiratory/cardiovascular depression in patients cardiopulmonary disease
Drug class of Midazolam
Benzodiazepine
What should you monitor in long term Clindamycin therapy?
CBC, BUN/Cr, LFT
ADRs of Clindamycin
rash, GI upset, candida, CDAD, hypersensitivity, agranulocytosis
DIs of Clindamycin
erythromycin (antagonistic effects), neuromuscular blockers (prolongation of effects)
Opioids used for severe pain from least to most potent
Morphine
Hydromorphone (Dilaudid) x5
Fentanyl x100
Potent opioid that is safe in renally impaired patient?
Fentanyl
Maybe Hydromorphone, but NO morphine
Opioid that has longest duration
Fentanyl patch (48-72 hr)
Kappa opioid receptor agonist and Mu receptor antagonist
Nalbuphine
Nalbuphine has much less risk of _________ and _________ than morphine.
abuse potential (use to get off opioids) respiratory depression
MOA of Ketorolac/Toradol
NSAID, nonselective COX inhibitor
analgesic and anti-inflammatory
Indications of Scopolamine
motion sickness
PONV
Antiemetic that inhibits H1 muscarinic receptor
Promethazine
Important ADR of Promethazine
Neuroleptic malignant syndrome
Bone marrow suppression
Anticholinergic muscarinic antagonist that is used to treat nausea and vomiting
Scopolamine
What is the maximum dose of lidocaine?
5mg/kg
Indications of IV Dantrium
Muscle spasms
Malignant hyperthermia
Antidote of amphetamines
None available
