exam 1 Flashcards by Callie Wanek

Respiratory depression
GI: nausea and vomiting, constipation
CNS: dizziness, psychoses, anxiety, hallucinations, sedation
GU: ureteral spasm, urinary retention
Sweating and dependence less likely

narcotic agonists antagonist side effects

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Strongly binds to opioid receptors, mu, kappa, sigma, but does not activate them

greatest affinity for mu

Blocks the effect of opioids in the system
utilized for overdose treatment

narcotic antagonist action

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Ergot Derivative

sublingual
combined with caffeine in Cafergot for increased absorption from GI tract

ergotamine

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Rapidly absorbed from many sites
Metabolized by the liver and excreted through the urine

(nasal spray, oral, subq)

triptans pharm

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Hemorrhage
Shock
Burns
Acute liver failure
Neonatal hemolytic disease

Use may be limited due to cost

colloids use

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butorphanol (stadol)

narcotic agonist antagonist

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Mainstay of treatment before development of triptans

Block/Bind alpha-adrenergic and serotonin-receptors in the brain, which causes vasoconstriction of the cranial vessels (decreased cranial artery pulsation, decrease in hyperperfusion of the basilar artery bed)

Can prevent or abort a migraine

ergot derivatives actions

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0.9 nacl

isotonic crystalloid solution

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3 and 5 nacl

hypertonic solution

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Plasma and coagulation factors

Frozen immediately after donation and thawed before use

can be stored for up to a year
once thawed, it’s good for 24 hours

Used for bleeding caused by coagulation factor deficiency and plasmapheresis
-not used for simple volume expansion

Needs to be typed but not crossmatched

Infuse as fast as tolerated, must be within 4 hours

fresh frozen plasma

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A sensory and emotional experience associated with actual or potential tissue damage

pain

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small, myelinated (insulation-outside coating- for the nerves), respond quickly to pain

a delta fibers

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small, unmyelinated, slow conducting (contribute to chronic pain)

1) Pain impulses are conducted through these fibers to the dorsal horn of the spinal cord
2) They are then transmitted to the brain

c fibers

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large-diameter sensory nerves that enter the dorsal horn of the spinal cord

Do not transmit pain impulses, instead transmit touch and temperature
Conduct impulses more rapidly than small fibers
Can block smaller fibers from transmitting their signals

a fibers

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The transmission of impulses can be modulated or adjusted all along the spinal cord

Interneurons act as “gates” by blocking ascending transmissions of pain

The “gate” can be closed by:

stimulation of the A fibers*
descending impulses from the cerebral cortex, limbic system and reticular activating system
Learned experiences, cultural expectations, individual tolerance, and placebo effect can activate descending inhibitory nerves from the upper CNS
Many strategies need to be considered along with medication

gate control theroy

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Receptor sites that respond to naturally occurring endorphins and enkephalins (enkephalins substance that regulates substance P–makes pain signals more intense and promotes inflammation)

Found in CNS, on nerves in periphery, on cells in GI tract

Help to control blood pressure, pupil size, GI secretions, chemoreceptor trigger zone (CTZ) –(has to do with nausea, respirations), pain

opioid recptors

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Endorphins are released during stress to block the sensation of pain

In the limbic system (memories and emotions), receptors incorporate an emotional response to pain

Pain is subjective and can be assessed through many methods

A pain management plan should include nonpharmacological treatments

pain response

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pain-blocking
respiratory depression
euphoria
decreased GI activity
pupil constriction
physical dependence

mu pain receptors

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some analgesia
pupil constriction
sedation
dysphoria

kappa pain recptors

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react with enkephalins

beta pain receptor

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pupil dilation
hallucinations
dysphoria
psychoses

sigma pain receptor

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React with opioid receptors throughout the body to cause analgesia, sedation, and euphoria

narcotic agonist action

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IV administration is most reliable, IM and subq have varying rates of absorption

Metabolized by the liver and excreted through bile and urine

Cross the placenta and enter breast milk

narcotic agonist pharm

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Respiratory depression, cardiac arrest
Orthostatic hypotension
GI: nausea and vomiting, constipation
CNS: dizziness, psychoses, anxiety, pupil constriction, sedation (addiction)
GU: urinary retention, ureteral spasm
Sweating and dependence

narcotic agonist s/e

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``` Head injury, increased ICP Alcoholism Respiratory dysfunction After GI or GU surgery Diarrhea caused by toxic poisons Liver or renal dysfunction Most are pregnancy category C, oxycodone is drug of choice because category B ```

narcotic agonist contraindications

Monitor clients for respiratory compromise with multiple CNS depressants Rare instances of serotonin syndrome have occurred when combined with SSRIs, SNRIs, MAOIs, TCAs, and most triptans (agitation, confusion, sweating, fever, muscle rigidity, diarrhea, headache)

narcotic agonist interactions

Perform pain assessments on a regular basis Provide medications before pain is severe Monitor bowel movements and treat constipation proactively Utilize non pharmacological methods Monitor respiratory status and LOC before administering Reassure risk of addiction is minimal when used correctly Monitor units of measurement

narcotic agonist n/c

Narcotic Agonist works primarily on mu receptors rapid onset, peak in 20-90 minutes can be used for acute or chronic pain slow IV push, may dilute to ease titration (1mg per minute)..

morphine

narcotic agonist | moderate pain

hydrocodone

narcotic agonists moderate to severe pain

oxycodone

narcotic agonist moderate to severe pain

hydromorphone

narcotic agonist for most severe pain

fentanyl

Act at specific opioid receptor sites to produce analgesia, sedation, euphoria, hallucinations Block opioid receptors that may be stimulated by other narcotics Three functions: relief of moderate to severe pain adjunct to general anesthesia relief of pain during labor and delivery

narcotic agonist antagonist action

Readily absorbed after IM administration Reach peak levels rapidly when given IV Metabolized by the liver, excreted in urine and bile

narcotic agonist antagonist pharm

Use caution with physical dependence on narcotics (Withdrawal) Respiratory dysfunction Renal or hepatic dysfunction Care with MI or CAD due to cardiac stimulation

narcotic agonist antagonist contraindications

Monitor for respiratory depression with multiple CNS depressants Pentazocine combined with tripelennamine (old form of antihistamine) produces hallucinations and euphoria similar to heroin (Ts and Blues)

narcotic agonist antagonist interactions

Narcotic Agonist-Antagonist relief of moderate to severe pain anesthesia adjunct has an oral form rapid onset when given IV

pentazocine (talwin)

buprenophrine (buprenex)

Narcotic Agonist-Antagonist

``` Usually due to blocking of opioid receptors nausea and vomiting sweating tachycardia hypertension tremors anxiety A naloxone challenge will help avoid acute reactions ```

narcotic antagonist s/e

``` Can be administered: subcutaneously IM IV orally nasal spray Metabolized by the liver and excreted in the urine ```

narcotic antagonists pharm

Pregnancy and lactation: category C, limited human data, will cause fetal withdrawal Narcotic addiction: withdrawal syndrome Cardiovascular disease: could exacerbate symptoms due reversal of depressive effects

narcotic antagonists contraindications

May need larger dose to reverse narcotic agonists-antagonists

narcotic antagonist interactions

Open airway, ventilate with ambu bag, administer vasopressors as needed Provide comfort measures to assist with withdrawal Those receiving naltrexone should be narcotic-free for 7-10 days to avoid acute withdrawal Monitor for response, may need additional dosing Usually supplied as 0.4mg/ml, give 0.4-2mg IV q 2-3 minutes, max dose 10mg consider other causes of resp. depression if doses do not work

narcotic antagonist n/c

Several syndromes which cause severe, throbbing headaches on one side of the head May or may not have an aura Signs and symptoms: pulsating pain nausea and vomiting sensitivity to light and sound Cause: - Thought to be due to arterial dilation, Cause of dilation not well understood - bradykinins - serotonin - other hormones or chemicals Those with an aura are associated with hypoperfusion of the brain during the aura with reflex arterial dilation

migraine headaches

Rapidly absorbed through many routes Ergotamine (sublingual combined with caffeine in Cafergot for increased absorption from GI tract) Dihydroergotamine (nasal spray, IM, IV drug of choice if oral is not tolerable, Onset of action 15 - 30 minutes)

ergot derivatives pharm

Related to vascular constriction CNS: numbness, tingling, muscle pain Stimulates the CTZ - nausea, vomiting, GI upset, diarrhea CV: pulselessness, chest pain, arrhythmias, MI Drug dependency with prolonged use, withdrawal syndrome may need hospitalization for safe withdrawal

erot derivatives s/e

peripheral vascular disease CAD Impaired liver function Pregnancy and lactation uterotonic activity inhibit prolactin Pruritus could become worse Monitor for malnutrition CTZ stimulation

ergot derivatives contrain

Care with beta-blockers due to increased risk of peripheral ischemia and gangrene

ergot derivatives interactions

Ergot Derivative nasal spray, IM, IV drug of choice if oral is not tolerable Onset of action 15 - 30 minutes

dihydroergotamine

Bind to selective serotonin receptors, which causes vasoconstriction of cranial vessels and reduced inflammation Used for the treatment of acute migraines, not prevention Clients can have poor response to one triptan and respond well to another Benefit is fewer side effects

triptans action

Related to vascular constriction CNS: numbness, tingling, burning, dizziness GI: dysphagia, abdominal pain CV: blood pressure alterations, chest pressure and tightness Almotriptan has fewer side effects than others

triptans s/e

As a class triptans are contraindicated during pregnancy and breastfeeding human data is scarce sumatriptan is generally considered safe do the benefits outweigh the risks? Renal and hepatic dysfunction CAD

triptans contrain

Combining triptans and ergot drugs results in risk of prolonged vasoactive reactions Do not use within two weeks of an MAOI due to increased vasoconstrictive effects MAO enzyme also breaks down some triptans Almotriptan, Rizatriptan, Sumatriptan, Zolmitriptan Care must be taken when combining with SSRIs and SNRIs due to rare risk of serotonin syndrome

triptans interactions

Administer at first sign of migraine, don't wait until severe Provide comfort, including non-pharmocological therapies Monitor for vasoconstrictive effects Safe use for children has not been established Monitor older adults closely due to chronic disease

triptans n/c

Triptan nasal spray, oral, subcutaneous subcutaneous pen has rapid onset oral onset 1 -1.5 hours wait 2 hours between doses

sumatriptan (imitrex)

zolmitriptan (zomid)

triptan

measure of the number of dissolved particles in 1 L of water sodium is greatest contributor glucose and urea normal osmolality is 275-295 nOsm/kg (300)

osmolality

ability of a solution to cause a change inwater movement across a membrane due to osmotic forces relative concentration of IV fluids isotonic, hypertonic, hypotonic

tonicity

Travel between compartments though a semipermeable membrane Intracellular fluid - two thirds of total body water Extracellular fluid - one third of total body water plasma interstitial space There is a continuous exchange, turnover, and mixing of fluids between compartments

body fluids

most important mechanism for regulation is thirst - hypothalamus senses the ECF is hypertonic - saliva decreases, leads to dry mouth, person drinks hypothalamus directs pituitary to release ADH -acts on kidneys to increase water reabsorption intake average- 2500ml of fluid per day output- kidneys, lungs, skin, feces, sweat RAAS (rennin, aldosterone) - aldosterone is secreted by the adrenal glands - aldosterone causes kidneys to retain sodium and water

fluid regulation

imbalance disorder - dehydration and shock - treated with oral and/or IV fluids

fluid deficit

imbalance disorder -treated with diuretics

fluid excess

to diagnose and correct the underlying cause -administer supporting fluids and medications to stabilize the client

imbalance disorders goal

IV solutions that contain electrolytes and other agents in concentrations that closely mimic the body's extracellular fluid Capable of quickly diffusing across membranes, leaving the plasma, and entering interstitial fluid and ICF Sodium is most common electrolyte, dextrose is another common additive Isotonic Hypotonic Hypertonic

crystalloids

Same osmolality as plasma Expand the circulating intravenous volume, without causing major fluid shifts between compartments Used to treat fluid loss due to vomiting, diarrhea, or surgical procedures will help to raise the BP Also used to treat mild hyponatremia Care must be taken because they can cause fluid overload increased BP, crackles, edema, dyspnea 0.9% NaCl, LR, 5% dextrose in water (D5W)*

isotonic solutions

isotonic crystalloid solution Isotonic fluid that contains sodium, chloride, potassium, and calcium Also contains lactate which is metabolized into sodium bicarbonate by the liver can help with metabolic acidosis Used for fluid resuscitation following: - hemorrhage - surgery - burns

lactated ringers

isotonic crystalloid solution* quickly metabolized left as hypotonic solution

D5W

Raises the osmolality of the plasma and expands plasma volume by drawing water away from cells and tissues Used to relieve cellular edema, especially cerebral edema Overtreatment with hypertonic solutions can lead to excessive expansion of intravascular compartment 3% NaCl, 5% NaCl, 5% dextrose in normal saline (D5NS) Infusions of 3% NaCl or greater should have the serum sodium, chloride, and bicarbonate checked after the first 100ml

hypertonic solutions

hypertonic solution* dextrose metabolized, leaving normal saline left as isotonic (clinical effect)

D5NS

Dextrose added to any solution will increase the osmolality added as a source of calories 1L of 5% dextrose supplies 170 calories It is quickly metabolized leaving you with the underlying fluid D5W is isotonic but quickly becomes hypotonic after infusion D5NS is hypertonic but clinical effects are isotonic Water is formed during dextrose metabolism, enhancing rehydration D5W is often used to reconstitute medications

dextrose

Lower the serum osmolality, causes water to move out of the plasma and into the tissues and cells Used for those with hypernatremia or cellular dehydration Overtreatment with hypotonic solutions can lead to depletion of the intravascular compartment with resulting hypotension and peripheral edema Dehydration with normal BP = hypotonic solution Dehydration with low BP = isotonic solution 0.45% NaCl

hypotonic solution

0.45 nacl

hypotonic solution

Intravenous solutions containing large molecules that remain in the blood proteins, starches, other large molecules too large to cross the capillary membrane Draw water from the cells and tissues into the plasma through osmotic pressure often called plasma volume expanders 1) Blood product colloids: albumin*, plasma protein fraction, serum globulins 2) Synthetic colloids: dextran*, hetastarch

colloids

Protein extracted from whole blood or plasma *classified as both a colloid and blood product Maintains osmotic pressure and binds substances for transport such as medications, hormones, enzymes helps to maintain CO also administered for hypoproteinemia Allergic reactions are possible due to donor antibodies (extremely rare; fever, chills, dyspnea, rash, urticaria) Some may refuse due to religious preferences Monitor vitals and watch for signs of fluid overload

albumin

Can double the plasma volume in a matter of minutes effects last approximately 12 hours Effects: - increased BP, CO, SV, and urine output - HR and blood viscosity decrease Also reduces platelet adhesiveness, and improves blood flow through capillaries Monitor vitals continuously during administration to prevent hypertension Use cautiously in those with renal failure

dextran

RBCs with little plasma, some platelets, and WBCs - platelets and WBCs not functional - may cause allergic reaction Used to increase serum hemoglobin level - 1 unit increases hgb by 1g/dL and hct by 3% - transfusion usually occurs with a hgb <7g/dL Stored in refrigeration for up to 42 days Type and crossmatch required Only infuse with 0.9% NaCl Infuse as fast as tolerated, must be within 4 hours

prbc

Concentrate prepared from FFP -Factor VIII, von Willebrand factor, fibrinogen, fibronectin, Factor XIII Frozen immediately after donation and thawed before use -once thawed, it's good for 6 hours Used in the treatment of DIC, uremic bleeding, abruptio placentae, cardiothoracic surgery Preferably ABO of recipient Infuse as fast as tolerated, must be within 4 hours

cryoprecipitate

Platelets, plasma, few RBCs and WBCs Used to prevent bleeding - 1 unit increases the platelet count by 10,000/mm3 - often pooled as 6 units - transfusion usually occurs with plt <10,000/mm3 Stored at room temperature for 5 days agitated while stored to prevent clumping Preferably ABO of recipient due to reduced cell survival when not typed, no crossmatch Most likely to have bacterial contamination

platelets

Crystalloids: - 0.9% NaCl - best for brain injuries - LR - can help with acidosis - hemodilution concern O negative PRBCs: - 1 to 2 units - move to type specific when type and crossmatch done Colloids: - no major advantage over crystalloids - can affect coagulation - expensive FFP & Platelets: - minimize coagulopathy - 1 FFP for every 2 units blood

best fluid for hemorrhage

Major electrolyte in extracellular fluid Important link between water retention, blood volume, and blood pressure NaCl is administered for hyponatremia, <130 mEq/L - 0.9% or 3% - oral available Monitor for hypernatremia -lethargy, confusion, tremor, hypotension Monitor for pulmonary edema, especially with 3% NaCl Diuretics will reduce peripheral and pulmonary edema

sodium

Major electrolyte in the intracellular fluid Plays a critical role in muscular contraction and conduction of nerve impulses KCl is administered to treat/prevent hypokalemia - oral - tastes bad - IV - slow infusion, never push Monitor for hyperkalemia -dysrhythmias, heart block, twitching, fatigue, diarrhea Overdose -Dextrose with insulin, polystyrene sulfonate, Lasix, calcium chloride, sodium bicarbonate

potassium

Posture, balance, and movement are regulated by the spinal motor neurons These neurons are influenced by higher-level brain activity: cerebellum - conscious muscle movement basal ganglia - unconscious muscle movement Injuries result in local damage to either muscle or tendons pain and muscle spasm Damage to CNS neurons can cause sustained muscle contractions or spasticity Skeletal muscle relaxants can treat temporary or permanent damage

regulation of nerves and movement

the result of injury to the musculoseketal system (can be fixed) overstretching a muscle, wrenching a joint, tearing a tendon or ligament A flood of sensory impulses come into the spinal cord, are passed through interneurons to spinal motor nerves, causing contraction Contraction cuts off blood flow to muscle fibers, increasing lactic acid which causes pain

spasm

is the result of damage to neurons within the CNS (permanent) Results from an increase in excitatory influences or a decrease in inhibitory influences within the CNS exact presentation is dependent on location of damage

spasticity

``` Heat or cold therapy Hydrotherapy Therapeutic ultrasound Physical thearpy Manipulation Massage Topical herbal remedies - capsaicin, caster oil, menthol ```

non pharm treatment of muscle spasticity

NSAIDS & Tylenol skeletal muscle relaxants should be an alternative treatment option Research shows skeletal muscle relaxants are not more effective than NSAIDs in patients with acute back pain

first line treatment for muscle spasticity

Exact mechanism of action is unclear but it is thought they involve action in the upper or spinal interneurons sedation? all are CNS depressants Can be used alone or with other medications such as analgesics

centrally acting skeletal muscle relaxants mechanism of action

Centrally Acting Skeletal Muscle Relaxant Structurally similar to GABA (neurotransmitter)-- primary neuro inhibit transmitter-- calming down Used for spinal cord injuries or disease (long term treatment, permanent injuries) MS, cerebral palsy, ALS, trauma (spinal cord injury) PO or intrathecal pump pump allows for decreased dosing PO: start at 5mg 3x per day and slowly increase (due to side effects), max of 80mg/day IT: several test doses first, dosing highly individualized, 100-800mcg/day

baclofen (lioreseal)

Centrally Acting Skeletal Muscle Relaxant Acute management (hurt back carrying something) max of 3 weeks (2-3 weeks, no longer). no added benefit of having long term. Flexeril is a short term management Structurally similar to TCAs (no antidepressant effects except for sedation) should not be used with heart conditions Has anticholinergic properties constipation, urinary retention, drowsiness, dry mouth Can cause physical dependence with long-term use Usually 5-10mg 3x per day, also available in an ER form

cyclobenzaprine (flexeril)

Centrally Acting Skeletal Muscle Relaxant Benzodiazapine advantageous when anxiety precipitates spasm 2-10mg 3x per day, max 30mg/day

diazepam (valium)

Centrally Acting Skeletal Muscle Relaxant Alpha2-adrenergic agonist (inhibit motor neurons at the spinal cord level) short acting* (Similar to baclofen but is short acting, baclofen is longer acting) can be used for chronic conditions (MS, spinal cord injuries, etc.) 2-4mg 3x per day, max 36mg/day

tizanidine (zanaflex)

``` Contraindicated when spasticity contributes to locomotion, upright posture, or increased function Seizure disorder (*baclofen) Cardiac dysfunction (*baclofen) Muscle weakness Hepatic and renal dysfunction especially metaxalone & tizanidine Safety during pregnancy and lactation is not known do the benefits outweigh the risk ```

centrally acting skeletal muscle relaxant cautions

CNS depression may increase when taken with other CNS depressants including alcohol Cyclobenzaprine should not be used within 14 days of MAOIs (hypertensive crisis, seizures, death)

centrally acting skeletal muscle relaxants interactions

Taper dosage to avoid withdrawal (baclofen; prevent psychoses and hallucinations) Most are on the Beers list (monitor older adults closely) Chlorzoxazone may discolor urine, orange to purple-red Monitor for CNS effects

centrally acting skeletal muscle relaxants n/c

Enter the muscle to directly prevent muscle contraction They do not interfere with neuromuscular communication, cause lessened CNS effects ``` Botulinum toxin type A (Botox Cosmetic) Botulinum toxin type B (Myobloc) Dantrolene (Dantrium) Incobotulinumtoxin A (Xeomin) ```

direct acting skeletal muscle relaxants

Direct-Acting Skeletal Muscle Relaxant Interferes with the release of calcium from muscle tubules prevents skeletal muscle fibers from contracting Management of chronic muscle spasticity - spinal cord injury, cerebral palsy, MS - treatment for malignant hyperthermia Hepatotoxicty has been reported -women, elderly, and those on high doses at greatest risk Oral - 25mg per day, max 100mg 4x per day Parenteral - 1-3mg/kg (M.H.), rapid IV push, max 10mg/kg

dantrolene (dantrium)

- drowsiness, weakness, headache, diarrhea* or constipation, abdominal cramping, hepatitis - lower doses and gradual increase can help to avoid adverse effects

dantrolene (dantrium) adverse effects

Direct-Acting Skeletal Muscle Relaxant Bind to receptor sites of motor nerve terminals and block the release of acetylcholine -leads to local muscle paralysis Type A (Botox Cosmetic) - frown lines, axillary hyperhidrosis, cervical dystonia, strabismus, blepharospasm (chronic blinking), overactive bladder, chronic migraines Type B (Myobloc) - cervical dystonia Dose is 100 units, not to exceed 300 units/3 months Generally not absorbed systemically Usually lasts a few months ADVERSE EFFECTS: - redness and edema at injection site, headache - can migrate from injection site and cause breathing and swallowing difficulties, most notably in children

botulinum toxin

Contraindicated when spasticity contributes to locomotion, upright position, or increased function Hepatic disease, concurrent use of estrogrens Pregnancy and lactation pregnancy category C limited human data Respiratory depression Cardiac disease

direct acting skeletal muscle relaxants cautions

Monitor for signs of hepatitis, discontinue medication Monitor IV infusions of Dantrolene closely, can cause extravasation Establish therapeutic goals at the beginning of therapy Periodic drug "holidays" may be needed with dantrolene to ensure effectiveness Discontinue dantrolene if diarrhea becomes severe, may need lower dose

direct acting skeletal muscle relaxants n/c