Pharmacokinetics and Pharmacodynamics Flashcards
What class of drug is most commonly used to treat bronchospasms?
sympathomimetics
What is the danger of pt taking over the counter antihistamines with a history of cardiovascular disease?
hypertension
Patients taking ACE inhibitors medication may experience?
chronic, dry cough
Most common side effect of sympathomimetics?
tachycardia
stimulation of alpha-2 receptors suppresses the release of what?
norepinephrine
Sublingual nitroglycerin has what type of onset and bioavailability?
sublingual route has a rapid onset but low bioavailability
Ipratropium bromide (Atrovent) causes bronchodilation antagonzing which receptors?
antagonizing muscarinic receptors
ACE inhibitor medications lower the blood pressure by blocking?
Blocking the conversion of Angiotensin I to Angiotensin II
What is the most commonly prescribed diuretic that inhibits sodium transport within the distal tubule of the kidney
Thiazide
What does alpha 1 receptor do?
constrict blood vessels
What does alpha 2 receptor do?
smooth muscle contraction, inhibit insulin, introduction of glucagon, suppresses norepinephrine
What does beta I receptor do?
inotropy, chronotropy, dromotropy
What does cholinergic mean?
Acetylcholine (neurotransmitter) meaning parasympathetic
dromotropy
refers to the strength of conduction of electrical impulses
chronotropy
heart rate
Which catecholamine has less vasoconstriction than epinephrine or norepinephrine?
Dopamine
What is the most common dose of dopamine used in the field?
5-10 mcg/kg/min
Can dopamine and dobutamine treat hypovolemic shock?
NO
What can you treat with dopamine and dobutamine?
hypotension or shock
What is the agonist affect of nicotinic?
Allow acetylcholine to stimulate muscle contractions
Which medication can not be given to pregnant women unless absolutely necessary?
hydralazine (vasodilator used to treat hypertension)
Calcium increases what property of the heart?
The strength of the heart’s contraction = contractility
Calcium ____ coronary arteries and peripheral arterioles.
vasoconstricts
Which node fires first?
SA node
After the SA node fires, which node fires next?
AV node
What are abnormal pacemaker sites within the heart (outside the SA node)?
ectopic foci
What is a premature ventricular contraction?
A single impulse that originates at the right ventricle
To fix slower rhythms, you need?
calcium
How do you fix faster rhythms?
sodium and potassium
What is outside of the cell? Sodium or potassium?
Sodium
What is inside of the cell? Sodium or potassium?
Potassium
The Vagus nerve releases which neurotransmitter?
ACH
What is an indication for class I, sodium channel blockers?
ventricular dysrhythmias
What does Class IB agents do?
slow conductions through the ventricles, increase v-fib threshold, reduce automaticity/ectopic foci
What is needed to treat Torsades de Pointes?
Magnesium- bc a magnesium deficiency is what causes Torsades de Pointes.
What is one example of a Class IB Agent?
Lidocaine (Xylocaine)
Beta 1 receptors in the heart attach to which channels?
calcium
What is used to treat HTN, angina, supraventricular tachycardia?
beta blockers
Used to treat tachydysrhythmias brought on by the sympathetic nervous system
beta blockers
Class III
potassium channel blockers
Do potassium channel blockers shorten or extend the refractory period
Prolongs repolarization which extends refractory period
What can be used to treat all tachydysrhythmias?
potassium channel blockers
What is the most common potassium channel blocker?
Amiodarone
Class IV
Calcium channel blockers
Prime side effects of calcium channel blockers
hypotension and bradycardia- slows does the heart because its decreasing the automaticity
Calcium channel blocker medications
Verapamil, Diltiazem, Nifedipine
Adenosine does what to the heart’s conductivity?
Decreases conduction velocity through the AV junction
Adenosine is not effective on?
A-fib(above the ventricle), A-flutter or ventricular dysrthmias
Where does Adenosine work?
The AV junction
Can adenosine be used to treat SVT?
yes
How does Diogoxin work?
Increases intracellular calcium which increases cardiac output and contractility. It also decreases AV conduction velocity.
Common agents for sedative hypnotics
eptimodate, fentanyl, midazolam
What is an analgesic?
decrease in perception of pain (not sensation)
What two classes of analgestic?
Opioid and non-opioids
What is an agonist?
binds to the receptor site and causes the expected response
What is an antagonist
binds to the receptor site and does not initiate the expected response (blocks the site)
A generic reference to morphine-like drugs/actions?
Opiates
What do opiods do?
Acts on endorphin receptors to decrease the ability to propagate pain impulses (Mu, Kappa, Sigma)
What do Sigma receptors cause?
AMS, hallucinations and delium
Examples of agonist-antagonist
nalbuphine (Nubaine), butorphanol (Stadol)
Example of pure opioid antagonist
naloxone(Narcan)
What is the cardiac load on analgesias?
Lowers preload and afterload
Miosis
excessive pupil constriction
Examples of adjunct medications/drugs that potentiate with opioids
caffeine, antihistamines, benzos
Naloxone is used for what type of overdose?
Treat heroin and opioid overdoses
Indication for Narcan(Naloxone)
Respiratory rate less than 8
Examples of Non steroidal anti-inflammatory drugs
Acetaminophen (Tylenol), Ibuprofen, Naproxen, Toradol(ketorolac), Salicylates (Aspirin)
How does Tylenol work?
Inhibits the synthesis of CNS prostaglandins (inflammatory response) and inhibits leukocyes migration and release of lysosomes
What is Ketorolac (Tordol)?
Anti-inflammatory effects are caused by decreased prostaglandin. Pain management related to decreased inflammation. Antipyretic
How can Ketorolac be given for vomiting pt?
IM or IV
What does Asprin inhibit the synthesis of?
inhibits the synthesis of cyclooxygenase(COX)
Aspirin effects
Bad:GI ulceration, increase bleeding, decrease renal elimination, decrease uterine contractions during labor
Good: pain relief, fever, inflammation
What decreases the neural impulses and loss of sensation?
anesthetics
Conscious sedation is also known as?
neuroleptanesthesia
How do local anesthetics affect?
affect on area around injection like lidocaine accompanies by epinephrine
Three examples of gas anesthetics
nitrous oxide(Notronox), halothane, Ether
Barbiturates do what?
Produce anesthesia and hypnosis but no pain relief; used for RSI
Onset and duration of barbiturates?
20-60 seconds, duration if 5 minutes
What are the three classes of sedative-hypnotic drugs?
Alcohol, Benzos, Barbiturates
Benzos promote which receptors?
Promote the effectiveness of GABA receptors
What part of the brain has a high concentration of benzo receptors?
amygdala (emotion center)
Examples of non-benzo benzos?
Zolpidem
Do barbiturates have a higher or lower respiratory depression than benzos?
high
Is there an antagonist for barbiturates?
No
Which barbiturate can be used for anti-seizures?
Phenobarbital(Luminal)
Magnesium sulfate
Blocks neurotransmission by decreasing ACH at motor nerve terminals
100gm of Thorazine is equivalent to what amount of Haldol?
2mg of Haldol
What is a treatment for extrapyramidal symptom?
Benadryl
TCAS block the reuptake of what?
Tricyclic antidepressants
Blocks the reuptake of NE and serotonin
What is the antidote for Tricyclic antidepressants
sodium bicarbonate
Most common side effects of SSRI’s
nausea, insomnia, sexual dysfunction
Common MAO medications
Nardil, Parnate, Marplan
What is the Mechanism of action for amphetamines?
Promote the release of norepinephrine and dopamine
Indications for Amphetamines
diet suppresion, decrease in fatigue, increase concentraion
Side effects of amphetamines
psychosis, insomnia, convulsion, hypertension, tachycardia
Mimics the effect of ACH causing depolarization, then paralysis
succinylcholine
What do alpha agonists do?
increase BP and constrict blood vessels
Parasympatholytic/anti-cholinezgic effects include?
drying and bronchodilation
Muscarinic effects can be blocked with what?
Atropine
Anticholinergics black ACH at what receptor sites?
muscarinic receptors
How long does Atropine last?
3-5 minutes
What is Myasthenia gravis?
autoimmune disorder that destroys nicotinic fibers and causes muscle weakness
What is used to block adrenergics?
beta blockers and alpha blockers
What reacts directly on alpha and beta receptors?
catecholamines
What are the three naturally occurring catecholamines?
epi, norepinephrine, dopamine
Is dopamine is dose dependant?
yes
What are beta blockers used for?
HTN, SVT, Angina, tachy-dysrhythmias
Prolonged repolarization with potassium channel blockers extends what?
refractory period
What Class III dysrhythmic can be used on all tachydysrhythmias?
potassium channel blockers
What is one example of an off-label medication in EMS?
IV Tranexamic Acid
What is one controversial Schedule I controlled substance?
Marijuana
What classification of medication has a high abuse potential but has legitimate medical purposes?
Schedule II
What classification of medication is likely to be be carried and administered by medics?
Schedule II(Fentanyl and Morphine Sulfate) and Schedule 4 such as Midazolam(Versed), diazepam(Valium) and lorazepam(Ativan)
Which classification of medication requires locked storage, record keeping and waste protocols?
Schedule 2-5
Which classification of medication is not recognized for medical purposes?
Schedule 1
Which classification of medication is has high abuse potential?
Schedule 1
Heroin, Marijuana, LSD and Peyote are what type of classification?
Schedule 1
How does Amio work within the cardiac cycle?
Prolongs phase 3 of the cardiac action potential cycle
What is the generic name for Atrovent?
Ipratropium Bromide
What is the effect of Adenosine?
Slows AV conduction time
What is the direct effect of glucagon?
mobilizes glycoygen storages
What is the effect of sodium bicarbonate on Ph blood level?
Increases blood Ph level
What is the effect of diphenhydramine?
Blocks histamine release by competing with H-1 receptors
How long should you administer Adenosine in duration?
1-3 seconds
What sign or symptom should you anticipate when administering magnesium sulfate?
hypercarbia
What is the effect of diltiazem(calcium channel blocker)?
Increases intracellular calcium
What is the mechanism of action for an analgestic?
increases the pain threshold in the CNS
What is the mechanism of action for an antipyretic?
blocks protaglandins in the hypothalamic thermoregulatory center of the brain
What produces endogenous pyrogens that increase prostalgandin in CSF?
leukocytes
What is the onset time for Acetaminophen?
30-60 minutes
What is the duration for Acetaminophen?
3-4hours
How do you treat for an acetaminophen overdose within 1 hour?
activated charcoal within 1 hour
How do you treat for an acetaminophen overdose over an hour?
Acetyllcysteine (Mucomyst)
Pediatric dose for Acetaminophen?
15mg/kg every 4-6 hours
Adult dose for Acetaminophen PR every 4-6 hours?
650mg
ADult dose for Acetaminophen PO every 4-6 hours?
325-650mg
What is the class for Acetazolamide?
carbonic anhydrase inhibitor
What is the indication for Acetazolamide?
prevention and treatment of acute mountain sickness
What does Acetazolamide cause the kidneys to secrete when the person is hyperventilating?
bicarbonate (alkaline)
What is tinnitus? (*side effect of Acetazolamide)
ringing, humming or buzzing in both ears
What is the adult dose for Acetazolamide?
500mg - 1g per day in divided dose
What is the pediatric dose for Acetazolamide?
500mg per day in divide dose
What form of medication is wax like that dissolves in the rectum or other body cavity
suppository
What form of medication is a sterile solution for direct injection into a body cavity, tissue or organ?
Parenteral solution
What are two examples of parenteral solution?
Fentanyl(Sublimaze) and Epinephrine
The stem “pril” signifies
ACE Inhibitor Medication Class
Cardiac medication digoxin is given based on the pt’s _______ body weight?
ideal body weight
Antidysrhythmic, Lidocaine, is administered based on the pt’s ______ body weight?
actual body weight
Which patients are disproportionately susceptible to paradoxical medication reactions- opposite to the intended effects of the medication?
Pt’s at extreme ages- infants and pt’s older that 65yr
Barbiturates can cause unexpected _____ in older patients.
excitement or agitation
Barbiturates can cause unexpected ___________ in children?
excitement or agitation
Fever suppresses the function of the ____________ in the liver
Cytochrome P-450
______________impairs effectiveness of medications used in traditional cardiac ALS.
hypotension
Patients with primary pulmonary hypertension experience acute decompensation when they receive _______ ___________.
vasopressors
-azole
antifungals
-ane
general anesthetics
-ase
thrombolytics(clot-blusters)
-azosin
alpha blockers (adrenergic antagonist)
-barbital
barbiturates
-caine
local anesthetics
-ciclovir
anti-virals
-curonium
neuromuscular blocker
-dipine
calcium channel blockers
-ine
stimulants
-lam/ -pam
benzodiazepines
-lol
beta blockers (adrenergic antagonists)
-lone
corticosteroids
-micin/-mycin
antibiotics
-prazole
proton pump inhibitors (anti-ulcers)
-pril
ACE inhibitor (antihypertensives)
-profen
NSAID (antiinflammatory)
-setron
5-HT3 Receptor Antagonists (antiemetics)
-sone
corticosteriods
-stigmine
Cholinergics
-stine
Anti-tumor
-terol
Bronchodilators
-thiazide
Potassium-losing diuretics
-tidine
H2 receptor antagonists (anit-ulcers)
-triptan
anti-migraines
-triptline
(anti-depressants) tricyclics
-vastatin
antilipemics (anti-cholesterol)
-zine
phenothiazines (antipsychotics, antiemetics)
-zoine
nasal decongestants
A non proprietary name of abbreviation of the chemical name
GEneric name
Name given to the drug by the pharmaceuticals companies that make the drug
Tradename/brand name
What are the 6 rights of medication administration?
Right drug
Right dose
Right time
Right route
Right patient
Right documentation
What describes the attraction between a drug and a receptor?
Affinity
Do drugs with a low affinity require a higher or lower concentration of the drug to get a response?
Higher
What is the amount of drug that is required to produce a therapeutic response?
Drug potency
What is the amount of drug that produces a response in 50% of people taking it?
Effective Dose
What is the amount of the drug that produces adverse effects in 50% if the people taking it?
Toxic dose
What is the ratio between in the Margin of safety?
Toxic Dose and the Effective Dose
What is it called when a reaction to a drug has significantly different response that what was expected?
Idiosyncrasy
What is the enhancement of one’s drug’s effect by another drug?
Potentiation
Opium, Morphine and Methadone are examples of what type of drug schedule?
Schedule II
Codeine, amphetamines, phenobarbital are examples of what type of drug schedule?
Schedule III
What is the study of metabolism and action of drugs?
Pharmacokinetics
What are the key organs in biotransformation, process of drugs being inactivated and eliminated from the body?
LIver, lungs, kidneys, intestines
When medication is administered through IV, what percentage of bioavailability does it have?
100%
Drug induced movement disorders caused by antipsychotics, which include side effects like uncontrollable movements, tremors, muscle contractions are called what?
Extrapyramidal Symptoms
List the most effective routes of administration to the least effect route:
IV - INH- Intraperitoneal - IM - PO - Topical
What type of medication is mixed with a liquid, usually water, cannot dissolve and requires to be shaken for even distribution?
Suspension
What type of medication is a mixture of two liquid components?
Emulsion
Nerve fibers that secrete norepinephrine are called what?
adrenergic nerve
Nerve fibers that secrete acetylcholine are called?
cholinergic nerve fibers
Which drugs mimic catecholamines or the release of norepinephrine causing a sympathetic response are called what?
Adrenergics
What do adrenergics cause in the lungs?
bronchial dilation
What do adrenergics cause in the pupils?
Pupils will dilate
What do adrenergics cause to the rate of the heart?
Increase the contractile force and heart rate
Which type of drugs inhibit the activity of the sympathetic nervous system?
Sympatholytics
What schedule of medication is Xanax, Valium, Ativan under?
Schedule IV
What is another word for mechanism of action?
pharmacodynamics
What level of evidence does Class I indicate?
Strong evidence supporting the use of medication for the condition
What level of evidence does Class IIb indicate?
Weak evidence
What level of evidence does Class IIa indicate?
moderate evidence
What level of evidence does Class III no benefit indicate?
the benefit equals the risk and intervention should not be performed
What level of evidence does Class III harm indicate?
strong evidence that the risk is greater than the benefit, intervention should not be performed
What class of drug is hydrocodone?
Schedule III
What kind of antagonist temporarily bind with cellular receptor sites to displace agonist chemicals?
competitive antagonists
What type of antagonist permanently binds with receptor sites and prevent the activation by agonist chemicals?
Noncompetative antagonists
What are two examples of a noncompetitive antagonists?
Ketamine and Aspirin
Which partial agonist binds to mu opioid receptors which minimizes opioid physical dependence but still produces analgesia; used to treat addiction.
Buprenorphine( Buprenex, Subutex)
What kind of agents bind with heavy metals in the body to create a compound that can be eliminated?
chelating agent
When bicarbonate ions bind with excess hydrogen ions from sodium bicarbonate, does it increase or decrease the blood ph?
Increase pH
A chemical that increases urinary output?
diuretic
What is the effect of diltiazem?
(Calcium channel blocker) Decreases intracellular calcium which leads to reduction in muscle contractions.
What is the Brand name for Sildenafil?
Viagra
What is the first line drug for a pulseless ventricular tachycardia?
Epinephrine
What is the antidote for benzodiazepine overdose?
Flumazenil
What is the primary neurotransmitter in the parasympathetic nervous system?
Acetlycholine
What is the primary effect of Adenosine?
Slows AV node conduction time
Muscarinic effects can be blocked with what medication?
Atropine
Which sympatholytics block adrenergic effects?
Beta blocker and Alpha blockers
Which medication is similar to Dopamine but it doesn’t increase HR as much and better for pt’s who are already tachycardic?
Dobutamine
What is the indication for sodium channel blockers?
Ventricular dysrhythmias
What is the MOA for Class IA agents?
slow conduction through the ventricles (widens QT intervals)
What does Class Ib Agents do the v-fib threshold?
Increase
Where do Beta1 receptors in the heart attach to?
Calcium channels
What is the indication for Class II Beta Blockers?
tachydysrhythmias caused by sympathetic stimulation, HTV, SVT, angina
These blockers prolong repolarization which extend refractory periods…
Potassium channel blockers
These blockers are similar as Beta Blockers but are useful in breaking slow SVT, A-fib, and A-flutter
Calcium Channel Blockers
Verapamil, Diltiazem and Nifedipine are what type of medication?
Calcium Channel Blockers
Which medication can be used for CHF, A-fib and A-flutter?
Cardiac Glycocides
What can be used for stable A-fib as a diagnostic to rule out PSVT?
Adenosine
What medication can be used to treat for A-fib, chest pain and high blood pressure?
Cardizem (Diltiazem) - Calcium Channel Blocker
What is a depolarizing neuromuscular blocking agent used for RSI?
Succinylcholine (Anectine)
How much is in a micro-drip tubing set?
60 gtts/mL
How much is in a macro-drip tubing set?
10 gtts/mL
For refractory V-fib or pulseless v-tach, how much Amiodarone is given?
300mg rapid IV/IO push
Are antidysrhythmics indicated for hemodynamic stable patients?
No
What is the correct dose and concentration of epi for a non-traumatic cardiac arrest?
0.1mg/mL or 10ML(1mg) every 3-5min
What are side effects of Atropine Sulfate?
thirst, dry mouth, pupil dilation, urinary retention (think anticholinergic)
What is the initial dose of Diltiazem to treat rapid ventricular rates with A-fib and A-Tach?
0.25mg/kg for IV
Does Nitro increase or decrease preload and afterload?
decrease
Are PVC’s routinely treated with antidysrhythmics?
No
What is the life saving drug for hyperkalemia?
Calcium
Peaked T waves, absent P waves and widened QRS complexes are signs of?
hyperkalemia
Inward sodium channels close the cell begins to repolarize during what phase?
Phase 1
-tan
ARBs (antihypertensive)
What is used to increase the heart rate by opposing the vagus nerve when it causes bradycardia?
Atropine Sulfate
What medication increases myocardial oxygen demand?
Atropine
What is the state of being insensible to pain while still conscious?
analgesia
A medication that causes the inability to feel sensation
anesthetic
The percentage of the unchanged medication that reaches systemic circulation.
bioavailability
Medications that bind with heavy metals in the body and create a compound that can be eliminated; used incases of ingestion or poisoning
chelating agents
Paralytic agents that act at the neuromuscular junction by binding with nicotinic receptors on muscles, causing fasciculations and preventing activation by acetylcholine
competitive depolarizing
Drugs used in the treatment of heart failure and certain atrial dysrhythmias
digitalis preparations
Aspirin blocks the formations of ….?
Thromboxane A2
Can Aspirin be used to dissolve existing thrombuses?
No, it can only be used to prevent existing throbuses from
What is an inotropic medication that increases cardiac contractility to improve perfusion?
Dopamine
Can PVC’s be treated with antidysrhythmics?
No
Digoxin is prescribed for patients with…?
heart failure, Afib, A-flutter
The mu opioid receptor complicates therapy for pain because it can cause….?
respiratory depression, dependence and constipation
What are three reasons to consider IO route?
Shock, seizures, cardiac arrest
What might happen if fluid leaks from an IO infusion outside the bone?
compartment syndrome
Where does medication undergo first-pass metabolism?
the liver
Where is the buccal region located?
between the gum and cheeks
Intranasal medication require how much more times the dose of IV medication?
2-2.5 times
Which 5 medications can be given IN?
Narcan, Versed, GlucaGen, Tordol (Ketorolac), Romazicon (Flumazenil), Fentanyl(Sublimaze)
What are the sites for IO medications?
proximal tibia, femur, distal tibia(medial malleolus), proximal humerus, sternum
Which opioid analgesic can cause hypotension?
Morphine
Which prehospital medications are known to cause fetal harm?
Aspirin and Benzos (diazepam, midazolam)
Is Lidocaine administered based on pt’s ideal weight or actual?
Actual weight
A fever is known to suppress the function of the _______ system in the liver, which decreases the rate of metabolism of certain medications.
cytochrome P-450
hypotension may occur with a dobutamine infusion because?
it decreases afterload
As a medication undergoes biotransformation, it becomes?
metabolite
What is a another name for adverse effects, clinical changes not desired and cause some degree of harm?
untoward effects
Promethazine(Phenergan) is an antiemetic that may cause?
hemodynamic and ECG changes
In first order elimination, where the plasma levels directly influence the rate of elimination, the more substance in the plasma, the more _______exists.
elimination
What is the time needed in an average person for the metabolism or elimination of 50% of the substance in the plasma?
half-life
What is the half-life of Aspirin?
15-20 minutes
What is the half-life of Klonopin (Clonazepam)?
19-50hrs
Dopamine is commonly used for?
non hypovolemic hypotension
first-pass metabolism of a medication occurs when?
bioavailability of a medication is reduced before it reaches the circulation
Antibiotics and antiseizure medications can cause Stevens-Johnsons syndrome which causes?
fatal reactions that mimics a burn
What is an example of summation/addition medication interactions where two medications with similar effects combine to produce an effect equal to the sum?
Tylenol and Advil which are both antipyretics.
What medication can be used to treat tricyclic antidepressant overdose with widening QRS interval, hypotension and arrhythmias?
sodium bicarbonate
When promethazine(Phenergan) is used with codeine to increase effects over one medication alone; this is an example of?
potentiation - one medication enhancing the presence of another, which does not produce the same effect
Which cardiac glycoside decreases heart rate and improves contractility?
Digoxin (Lanoxin)
Calcium Channel blockers common indication includes?
reduction of heart rate and BP
which alpha receptor inhibits insulin release and suppresses norepinephrine release?
Alpha 2
Glucagon is used in the treatment of beta-blocker overdose because it?
produces positive inotropic and chronotropic effects
IV calcium can be used as an antidote to treat?
Magnesium Sulfate overdose
What do alpha adrenergic receptors do?
lower blood pressure
Which medication can be used to reduce cerebral edema?
Mannitol
Which catecholamine stimulates the alpha receptors?
Norepinephrine
Which medication is needed when acetylcholinesterase is inhibited and acetylcholine increases?
Atropine
In up to 60% of all patients, morphine sulfate have the side effect of?
nausea and vomiting, fentanyl is referred
an example of a nondepolarizing paralytic is?
Rocuronium - fast onset, longer duration and less side effects than Succ
what is an example of a competitive depolarizing paralytic is?
Succinylcholine - binds with nicotinic receptors to prevent additional activation of ACh
What is a life-threatening side effect of Succ?
Hyperthermia with metabolic acidosis and muscle rigidity
What is the main effect of dobutamine?
increases inotropy
What is the effect of Nitroglycerin in cardiac related chest pain?
decreases preload and coronary vasodilation
What medication is used to decrease gastric acid secretion?
histamine-2 receptor antagonist
The renin-angiotensin system functions by?
vasoconstriction, fluid retention for hypotension or hypoperfusion
The vagus nerve releases _______, which acts on the ____________receptors.
ACh, muscarinic
