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EMERGENCY DRUGS Flashcards

1
Q

Drugs used in cardiac arrest?

A

Adrenaline IV

Amiodarone IV

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2
Q

Prescription of adrenaline in cardiac arrest?

A

 In cardiac arrest (pre-filled syringe 1:10,000, 1mg in 10mL)
• If shockable, adrenaline 1mg IV given after 3rd shock and repeated every 3-5 minutes
• If not shockable, adrenaline 1mg IV ASAP and repeated every 3-5 minutes

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3
Q

Mechanism of adrenaline in cardiac arrest?

A

 Potent agonist of A1, A2, B1, B2 adrenoreceptors
 Fight or flight sympathetic actions:
• Alpha-1 – Vasoconstriction
• Beta-1 - Tachycardia, inotropy, myocardial excitability
• Beta- 2 - Vasodilation of vessels in heart and muscles
• Bronchodilation and suppression of inflammatory mediators from mast cells

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4
Q

Side Effects of adrenaline in cardiac arrest?

A

 Hypertension
 Anxiety, tremor, headache, palpitations
 Angina, MI and arrhythmias

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5
Q

Contraindications of adrenaline in cardiac arrest?

A

 LA with adrenaline to areas supplied by end-artery (fingers, toes, penis) - tissue necrosis due to vasoconstriction

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6
Q

Dose of amiodarone in cardiac arrest?

A

 In cardiac arrest, given after 3rd shock
• 300mg IV, followed by 20ml of 0.9% NaCl flush
 Consider a further 150mg IV after 5 shocks

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7
Q

Mechanism of amiodarone in cardiac arrest?

A

 Block of Na, Ca and K channels
 Antagonist of α- and β-adrenergic receptors
 Reduce spontaneous depolarisation, slow conduction velocity, and increase resistance to depolarisation, including in the AV node

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8
Q

Side Effects of amiodarone in cardiac arrest?

A

 Hypotension during IV infusion
 Chronic – pneumonitis, bradycardia, AV block, photosensitivity, grey discolouration and thyroid abnormalities
 Long half-life and takes months to be eliminated

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9
Q

Dose of oxygen in acute pulmonary oedema?

A

 15L/min via non-rebreathe mask if severe

 If needed, CPAP, BiPAP and intubation

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10
Q

Mechanism of oxygen in acute pulmonary oedema?

A

 Increase PO2 in alveolar gas, driving more rapid diffusion into blood

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11
Q

Side Effects of oxygen in acute pulmonary oedema?

A

 Discomfort of face mask

 Dry mouth

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12
Q

Dose of furosemide in acute pulmonary oedema?

A

 IV 40-80mg furosemide slowly initially

 Subsequent boluses, IV infusion or maintenance may be needed

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13
Q

Mechanism of furosemide in acute pulmonary oedema?

A

 Act on ascending limb of loop of Henley
• Inhibit the Na+/K+/2Cl−co-transporter
• Responsible for ions transport from lumen into epithelial cells, water then follows
• Inhibition has diuretic effect
 Dilatation of capacitance veins
• Reduce preload and improve contractile function of heart muscle

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14
Q

Side Effects of furosemide in acute pulmonary oedema?

A

 Dehydration and hypotension
 Low electrolyte state – Urinary excretion of Na, Cl and K and increase excretion of Mg, Ca and H ions
 Hearing loss and tinnitus

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15
Q

Dose of nitrates in acute pulmonary oedema?

A

 Glyceryl trinitrate (2-5mg buccal) if BP>90 systolic
 Glyceryl trinitrate IV 50 mg in 50 ml 0.9% sodium chloride at 2 ml/hour, titrating up to 20 ml/hr, maintaining BP > 90 systolic

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16
Q

Mechanism of nitrates in acute pulmonary oedema?

A

 Converted to NO which increases cGMP synthesis and reduced intracellular Ca2+ in vascular smooth muscle cells causing relaxation
 Venous and arterial vasodilatation
 Relaxation of venous capacitance veins
• Reduce preload and LV filling
• Reduce cardiac work and myocardial oxygen demand

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17
Q

Side effects of nitrates in acute pulmonary oedema?

A

 Flushing, headaches, light-headedness and hypotension

 Tolerance with sustained use – nitrate free period overnight to minimise

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18
Q

Contraindications of nitrates in acute pulmonary oedema?

A

 Avoid in phosphodiesterase inhibitors – hypotension

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19
Q

Dose of morphine in acute pulmonary oedema?

A

 Diamorphine 2.5-5mg, at 1mg/minute IV slowly

 Morphine 5-10mg (lower in elderly), at 2mg/minute

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20
Q

Mechanism of morphine in acute pulmonary oedema?

A

 Relieves breathlessness alongside oxygen, furosemide and nitrates
• Blunt medullary response to hypoxia and hypercapnia to reduce respiratory drive and breathlessness
 Activation of opioid u receptors in CNS to reduce neuronal excitability and pain transmission
 Reduce sympathetic nervous system
• Reduce cardiac work and oxygen demand

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21
Q

Side effects of morphine in acute pulmonary oedema?

A 
	Respiratory depression
	Euphoria and detachment
	Nausea and vomiting
	Pupillary constriction
	Constipation
•	Increased smooth muscle tone and reduced motility
	Itching, urticaria and sweating
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22
Q

Contraindications of morphine in acute pulmonary oedema?

A

 Dose reduction – hepatic failure, renal impairment and elderly
 Avoid in biliary colic – spasm of sphincter of Oddi

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23
Q

Does of oxygen in acute severe asthma?

A

 15L/min via non-rebreathe mask

 Maintain oxygen saturations 92-96%

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24
Q

Mechanism of oxygen in acute severe asthma?

A

 15L/min via non-rebreathe mask if severe

 If needed, CPAP, BiPAP and intubation

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25
Side effects of oxygen in acute severe asthma?
 Discomfort of face mask |  Dry mouth
26
Dose of nebulised salbutamol in acute severe asthma?
 5mg every 15-20 minutes if not helping, or back-to-back |  Can combine with ipratropium bromide 500mcg
27
Mechanism of nebulised salbutamol in acute severe asthma?
 Stimulation of GPCR leads to smooth muscle relaxation • Improves airflow in airways  Stimulate Na/K/ATPase pumps on cell surface membranes • Shift of K into cells • Useful in hyperkalaemia
28
Side effects of nebulised salbutamol in acute severe asthma?
 Tachycardia, palpitations, anxiety, tremor |  Increase glucose levels
29
Dose of ipratropium in acute severe asthma?
 500mcg nebulised every 4-6 hours if needed
30
Mechanism of ipratropium in acute severe asthma?
 Competitively inhibit acetylcholine • Increase HR and conduction • Reduce smooth muscle tone • Reduce secretions
31
Dose of hydrocortisone in acute severe asthma/COPD?
 Asthma • IV 100mg every 6 hours until conversion to oral prednisolone • Or oral prednisolone 40mg OD if not too severe  COPD • IV 200mg
32
Mechanism of hydrocortisone in acute severe asthma?
 Upregulate anti-inflammatory genes and downregulate pro-inflammatory genes  Glucocorticoid effects • Supress circulating monocytes and eosinophils • Gluconeogenesis from fatty acids  Mineralocorticoid effects • Stimulate Na and water retention and K excretion in renal tubule
33
Dose of aminophylline in acute severe asthma?
Slow IV injection Child - 5 mg/kg (max. per dose 500 mg) Adult - 250–500 mg (max. per dose 5 mg/kg) Followed by IVI
34
Dose of magnesium sulphate in acute severe asthma?
o Given IV in severe acute asthma o Sometimes in polymorphic VT o Adult - 1.2g-2g over 20 minutes o Child 2-17 – 40mg/kg over 20 minutes (max 2g)
35
Drugs given in anaphylaxis?
``` Oxygen Adrenaline IV fluids Chlorphenamine Hydrocortisone ```
36
Dose of adrenaline given in anaphylactic shock?
 In anaphylaxis (0.5ml of 1:1000, 1mg in 1ml IM into anterolateral thigh) • Adults or child >12 years - 500mcg IM (0.5ml) • Child 6-12 years – 300mcg (0.3ml) • Child <6 years – 150mcg (0.15ml)  Repeat every 5 minutes if needed
37
Mechanism of adrenaline given in anaphylactic shock?
 Potent agonist of A1, A2, B1, B2 adrenoreceptors  Fight or flight sympathetic actions: • Alpha-1 – Vasoconstriction • Beta-1 - Tachycardia, inotropy, myocardial excitability • Beta- 2 - Vasodilation of vessels in heart and muscles • Bronchodilation and suppression of inflammatory mediators from mast cells
38
Side effects of adrenaline given in anaphylactic shock?
 Hypertension  Anxiety, tremor, headache, palpitations  Angina, MI and arrhythmias
39
Dose of IV fluids given in anaphylactic shock?
o 500-1000mls IV 0.9% NaCl
40
Dose of chlorphenamine in anaphylactic shock?
```  IV slowly/IM • Adult or child > 12 years - 10 mg • Child 6 - 12 years 5 mg • Child 6 months to 6 years 2.5 mg • Child less than 6 months 250 micrograms/kg ```
41
Mechanism of chlorphenamine in anaphylactic shock?
 Antagonist of H1 receptors  Histamine released from mast cells as a result of binding to IgE on cell surface  H1 increases capillary permeability, oedema (wheal), vasodilation (flare) and itch
42
Side effects of chlorphenamine in anaphylactic shock?
 Sedation
43
Contraindications of chlorphenamine in anaphylactic shock?
 Severe liver disease – precipitate hepatic encephalopathy
44
Dose of hydrocortisone in anaphylactic shock?
```  Anaphylaxis (IM or slow IV) • Adult or child > 12 years - 200 mg • Child 6 - 12 years - 100 mg • Child 6 months to 6 years - 50 mg • Child less than 6 months - 25 mg ```
45
Mechanism of hydrocortisone in anaphylactic shock?
 Upregulate anti-inflammatory genes and downregulate pro-inflammatory genes  Glucocorticoid effects • Supress circulating monocytes and eosinophils • Gluconeogenesis from fatty acids  Mineralocorticoid effects • Stimulate Na and water retention and K excretion in renal tubule
46
Drug given in benzodiazepine overdose?
- Flumazenil
47
Dose of flumazenil in benzodiazepine overdose?
 Flumazenil IV 200-300ug over 15s, then 100ug at 60s intervals  Needs expert advice before given
48
Mechanism of flumazenil in benzodiazepine overdose?
 Benzodiazepine antagonist | • Reverses CNS depression
49
Side effects of flumazenil in benzodiazepine overdose?
 Risk of provoking seizures
50
Drugs given in hypoglycaemia?
Glucose | Glucogon
51
Mild hypoglycaemia treatment?
o 10-20g oral fast-acting carbohydrate (GlucoGel, Lucozade, sugar lumps)  Repeat if necessary o If fixes then carbohydrate snack
52
Severe hypoglycaemia treatment?
 Glucagon • 1mg SC/IM (not suitable for alcoholics) • Given is IV access not available or at home  Glucose • 10g IV infusion as Glucose 20% in large vein (75-80mls) • Then oral glucose once patient recovers consciousness
53
Dose of IV fluids in hypovolaemic shock?
9% saline 500mls over 5-15 minutes |  Repeated up to 2L then expert help needed
54
Drug given in opioid intoxication?
Naloxone IV or IM
55
Dose of naloxone given in opioid overdose?
 IV injection • Initial 400mcg • 800mcg for up to 2 doses at 1-minute intervals if no response • Increased to 2mg for 1 dose if still no response  Can be given SC or IM if IV route not feasible but IV has more rapid onset
56
Mechanism of naloxone given in opioid overdose?
 Competitive antagonist to opioid receptors and reverses the effect of opioids
57
Side Effects of naloxone given in opioid overdose?
 Opioid withdrawal – pain, restlessness, nausea and vomiting, dilated pupils, cold/dry skins
58
Drugs given in seizures?
Lorazepam/Diazepam/Midazolam | Phenytoin
59
Dose of lorazepam in seizures?
 Given after 5 minutes, 1-2mg Lorazepam IV slow bolus up to 4mg • Repeat if necessary after 5 minutes
60
Mechanism of lorazepam in seizures?
 GABA is chloride channel and main inhibitory neurotransmitter in brain  Facilitate and enhance binding of GABA to GABAa receptor • More resistant to depolarisation
61
Side effects of lorazepam in seizures?
 Drowsiness, sedation |  Loss of airway reflexes
62
Dose and route of diazepam in seizures?
0.2-0.5mg/kg (maximum 20mg/dose) rectally as single dose |  Or 10mg IV
63
Dose and route of midazolam in seizures?
 Buccal in community |  IM 10mg single dose if >40kg, 5mg if <40kg
64
Dose of phenytoin in seizures?
 20mg/kg (maximum 2g/dose) IV as single dose |  Maintenance 100mg 6-8 hourly
65
Mechanism of phenytoin in seizures?
 Reduces neuronal excitability and electrical conductance | • Potential Na channels binding, prolonging inactivity
66
When and what drugs given in hyperkalaemia?
- Immediate treatment if K>6 with ECG changes or K>6.5 - Calcium gluconate or calcium chloride (IV) - Insulin-glucose solution (IV) - Salbutamol (nebs) - Calcium resonium (oral or PR)
67
Dose of calcium gluconate or calcium chloride in hyperkalaemia?
 10% Calcium gluconate 10ml IV via large vein over 5-10mins (up to 30ml)  10% Calcium chloride 10ml over 5-10 mins  Repeat dose after 5-10 minutes if no improvement in ECG
68
Mechanism of calcium gluconate or calcium chloride in hyperkalaemia?
 Raises myocardial threshold potential • Reduces excitability and risk of arrhythmias • Protect cardiac membrane
69
Dose of insulin-glucose solution in hyperkalaemia?
 10 units soluble insulin in 50ml 50% glucose over 5-15 minutes
70
Mechanism of insulin-glucose solution in hyperkalaemia?
 Drives K into cells, reducing serum concentrations | • Once stopped, K leaks back out of cells and only short-term measure
71
Dose of salbutamol nebs in hyperkalaemia?
 10-20mg nebulised (5mg back-to-back) over 10-20 minutes
72
Mechanism of salbutamol nebs in hyperkalaemia?
 Stimulate Na/K/ATPase pump causing K shift into cells
73
Dose of calcium resonium in hyperkalaemia?
 15g oral every 6-8 hours with lactulose |  30g BDS PR
74
Mechanism of calcium resonium in hyperkalaemia?
 Remove K from body by exchanging for Ca in resin |  Slow method

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