Pharmacology - CNS, GI/Genitourinary, Infection, Pain, Toxicology Flashcards
Types of medications that affect CNS
1) anti-convulsants vs anti-seizures
2) Anti-parkinsons - usually for motor and neural discombobulation
3) Clot busters and thrombolytics for CVAs and TIAs
4) Behavioural meds for Anti-anxiety, neurolytics, and mood disorders
5) Opioids - usually considered analgesia but also greatly depresses CNS pathway (including HR and RR)
6) Anti-histamines
What are the 3 main neurological conditions encountered in pre-hospital settings requiring medications?
1) seizures
2) CVAs & TIAs
3) Mental illness
Two things neurological meds do
excite or suppress the CNS (uppers or downers)
Prime seizure disorder
epilepsy - idiopathic etiology
True or False. ABIs/TBIs can lead to seizures
True
True or false. If epilepsy disorders are not from an organic disorder (like febrile seizures, TBI) these can be corrected.
True
What is a seizure and how will the patient present?
- result of chaotic abnormal high frequent firing of neurons which can cause an altered LOC
- neurons are rapid firing with no organization, no rhythm to body
- patient is unconscious, no lash reflex
- eyes will deviate up to the left/right (to the side of the seizure in the brain)
Time frame for seizures
few seconds to 30 seconds, no more than 2 minutes
if > 2 min, high chance of brain cell death & severe cognitive impairment
True or false. Anti-Epiletic drugs will stop a convulsion once its started
False
Status epilepticus
ongoing and prolonged; starts and doesn’t stop OR continuous intermittent seizures (back to back i.e. one rolling right into the other)
True or False. Seizures typically resolve without treatment
True
What are pseudoseizures and what may a patient present like?
- by scientific definition - a psychiatric disorder brought on by stress or mental illness; a factitious disorder
- aka “fake seizures” - convulsing only, no organic brain involvement
- protected reflexes are still intact (i.e. lash reflex), can follow commands, hear. protect self, etc.
- cannot alter homeostatic balance
- roll eyes up/down or stare off into space
Pseudoseizures are now more commonly replaced with what term?
non-epileptic seizures
Pseudoseizures happen more commonly in what population
adolescence to early 20’s - more often in women
Epilepsy is most commonly diagnosed when?
before onset of puberty (usually in childhood)
Epilepsy
recurring seizures due to a brain disorder (organic brain dysruption)
Why do febrile seizures occur and what would be the appropriate treatment?
Usually triggered by fever/when kid gets too hot, the body is trying rid of excess heat but if the body cannot handle it, it will cause seizures to generate energy and give off this excess heat
Treatment: tylenol (anti-pyretic), remove clothes
Primary vs secondary seizures
Primary (idiopathic): undetermined cause - dx at a young age, accounts for ~50% of epilepsy cases
Secondary (symptomatic): distinct cause is identified
- trauma (sports, etc.); infection (sepsis); cerebraovascular disorders (TBIs, strokes, pregnancy); withdrawal (alcohol)
What are convulsions?
involuntary spasmodic contractions of any or all muscles through the body, including skeletal, facial, and ocular muscles
Is epilepsy the same thing as convulsions?
no. epilepsy is a chronic, recurrent pattern of seizures and a symptom of epilepsy would be convulsions
What are some common causes of seizures?
- TBIs/ABIs
- Epilepsy
- high fevers
- Anoxia (BP dropping so significantly due to lack of blood to the brain)
- Medicines,
- certain diseases
- alcohol/drug withdrawal
- trauma
- infection
- cerebrovascular disorders
What are the 3 main types of seizures?
Focal - aka partial onset seizures
generalized
unknown
Describe the different categories of focal seizures.
1) Simple partial - aka petite mal/focal aware seizure: these patients are aware during the seizure and the seizure is happening in one small part of the brain
2) Complex partial - aka focal impaired awareness seizure: these patients are confused or their awareness is affected in some way during a focal seizure
3) Secondary generalized tonic-clonic: a seizure that starts in one area of the brain, then spreads to both sides of the brain as a tonic-clonic seizure
Describe what a focal seizure is and its clinical presentation
- abnormal electrical activity that occurs in one or more parts of one brain hemisphere; partial seizure
- It begins in one area (“focal”) and may progress to others, leading to a general seizure (bilateral tonic-clonic)
- they are aware or have impaired awareness
- can have motor or non-motor onset
- eyes will deviate to the side of the brain where the seizure is occurring
Describe the clinical presentation of a patient with generalized seizures.
- previously known as grand mal seizures
- seizure that affects both sides of the brain
- usually motor (tonic- clonic or other motor) OR non motor (absence seizures - eyes may be oscillating)
- involves the whole body
What is an unknown onset seizure?
unclassified/idiopathic, can be focal or generalized and motor or non-motor
Describe the clinical presentation of an absence seizure.
- generalized onset seizure that is non-motor
- brief abnormal electrical activity in a person’s brain (very short lasting, several seconds)
- they look like they’re staring off into space/blanking
- lack of awareness during period of seizure
Benzodiazepines are considered what type of medication?
anti-convulsant meds & CNS depressant
What are the two main benzodiazepines and how do they work?
- Diazepam (Valium)
- Lorazepam (Ativan)
How it works: binds with gamma-aminobutyric acid (GABA) in the CNS which increases its natural effect and resultant decrease in activity in the CNS
- affects hypothalamic, thalamic, and limbic systems of the brain
- does not supress REM sleep as much as barbituates do
- does not increase metabolism of other drugs
*these actually STOP the convulsions hence anti-convulsants
The most common form of benzodiazepines used in prehospital setting?
Versed (Midazolam)
Anti-seizure medications are known as
anti-epileptic drugs (AEDs)
Goal of anti-epileptic drugs
- to control or prevent seizures while maintaining reasonable quality of life
- elongates time between seizures, and dramatically reduces the time frame of seizure if you do have a seizure
- minimizes adverse effects and drug-induced toxicity
- usually life-long, and a combination of drugs may be used
A patient goes to his doc and reports that his initial anti-epileptic drugs are no longer working even though they have worked for him in the last 5 years. What would be the doc’s next appropriate step?
To consider potential changes in the patient’s lifestyle which can affect how well they respond to their meds. If the AED was initially working and now isn’t, patient should be switched to a new AED
List 9 anti-seizure meds/AEDs.
1) Carbamazepine (Carbatrol, Tegretol)
2) Phenytoin (Dilantin)
3) Valproic acid (Depakene)
4) Oxcarbazepine (Trileptal)
5) Lamotrigine (Lamictal)
6) Gabapentin (Neurontin)
7) Topiramate (Topamax)
8) Phenobarbital
9) primidone (Mysoline)
What AED can be prescribed to someone who does not have epilepsy? What else could this drug be used for?
Gabapentin - helps with neurons so peripheral vascular disease, neuropathic pain, shaking, diabetes, restless leg syndrome, anxiety/sleeping
Patients who are phenobarbital usually have what diagnosis?
schizophrenia or hx of psychosis
Upon assessing the current medication list of a patient. The drug Gabapentin (Neurontin) is listed, but the patient states that he does not have any problems with seizures. You suspect that the patient:
- Is unaware of his own disease history
- Has been taking his wife’s medication by mistake
- May be taking this drug for neuropathic pain
- Is reluctant to admit to having a seizure disorder
c) May be taking this drug for neuropathic pain
Parkinsons Disease - What is it, symptoms, prevalence
- progressive nervous system disorder that affects movement
- symptoms start gradually (i.e. barely noticeable tremor in one hand)
- onset around 40s but most common in aged (prevalence increases with age)
- tremors are common but disorder also commonly causes stiffness or slowing of movement
Parkinson Disease medication - what is it and how does it work?
- carbidopa-levodopa (Sinemet)
- most effective parkinsons disease
- a natural chemical that passes into the brain and then gets converted to dopamine (as Parkinsons is thought to be due to lack of dopamine)
What are the two types of strokes?
CVAs and TIAs
Cerebrovascular accidents (CVAs)
- occurs when blood supply to the brain is interrupted/reduced, which deprives oxygen and nutrients from the brain leading to brain cell death
- can be caused by blocked artery (ischemic stroke) or leaking/bursting of a blood vessel (hemorrhagic stroke)
- aneurysms rupturing can also cause stroke
- plaque build up (clot or ischemia)
- main risk factor: HTN and high cholesterol
Transient Ischemic Attacks (TIAs)
- similar to a stroke but usually lasting only a few minutes and causes no permanent damage
- it’s the body’s way of alerting you that more problems are coming (CVA) - warning system with no time frame (i.e. a stroke may occur right after a TIA or in 2 years)
____% of strokes are ischemic.
____% of strokes are hemorrhagic.
80% are ischemic strokes - high % of survival
20% are hemorrhagic
What is the 80/20 rule for hemorrhagic strokes?
of the 20% that are hemorrhagic strokes, 80% are fatal and 20% will survive
What is the one clinical presentation that may help you distinguish between hemorrhagic and ischemic stroke?
seizures - occur in hemorrhagic strokes
An elderly patient presents with headache, blurry vision, and a SBP of 210. What are potential concerns re: this clinical presentation?
risk of stroke
Medications used for CVA/TIAs (classifications and common meds)
1) Anticoagulants: drugs that help keep the blood from clotting easily by interfering with blood clotting process
- Warfarin (Coumadin): preventative medication to prevent blood clots from forming or prevent existing clots from getting larger (prescribed following a stroke)
- ASA - low dose, daily
2) Antiplatelets: drugs that make it more difficult for platelets in your blood to stick together
- Clopidogrel (Plavix) to prevent blood clots; common taken with ASA
- exclusive for ischemic strokes/MIs because you’d be making a hemorrhagic stroke worse if you give them Plavix
3) Tissue Plasminogen Activator (tPA): thrombolytic - the only stroke medication that breaks up a blood clot & common emergency tx during a stroke; given IV/into an artery
- not for everyone; those with high risk of bleeding into their brain are not given tPA (or else they will continue to bleed into the injury site)
What are three main emotional and mental disorders?
1) anxiety
2) affective disorders
3) psychoses
Behavioural medications are given to what three categories of mental illness?
1) anxiety and depression
2) psychosis and mood disorders
3) Palliative MH - those with true MH issues
Anxiety vs Depression
Depression: Major Depressive Disorder (MDD) - common and serious medical illness that negatively affects how you feel, the way you think, and how you act
- causes feelings of sadness and/or loss of interest activities once enjoyed
Anxiety: unpleasant state of mind characterized by sense of dread and fear
- may be based on actual anticipated or past experiences
- may be exaggerated responses to imaginary negative situations
*Anxiety and depression go hand in hand - highly likelihood that if they’re dx with one, they have the other too
What are the 6 major anxiety disorders?
- OCD
- PTSD
- GAD
- Panic Disorder
- Social Phobia (social anxiety disorder)
- Simple phobia
What are affective disorders (mood disorders)?
- MH disorders characterized by changes in mood ranging from mania (abnormally pronounced emotions) to depression (abnormally reduced emotions)
- some patients may exhibit both mania and depression such as BPD
Descibe what bipolar disorder is and signs and symptoms.
- brain condition with symptoms including shifts in mood, energy level and activity
- serious disorder that causes individual to struggle with everyday life activities and can affect every area of life
- characterized by EXTREME depression and manic that is of gradual onset swinging from one to the other extreme (episodes are months long)
-
S/S:
- Mania: extremely high energy; grandiose levels of self-esteem; loud, rapid speech; very little need for sleep; engaging in risk behaviours like unprotected sex
- Depression: feelings of lethargy (both physically and mentally); sense of personal worthlessness; eating too much/too little; overwhelming sadness; suicidal/homicidal thoughts
Descibe what schizophrenia is and signs and symptoms
- A serious mental disorder in which people interpret reality abnormally
- may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning and can be disabling
- to be diagnosed, one must experience at least two of the following S/S for 6 months including one of the first three:
- delusions, hallucinations, disorganized speech
- catatonic behaviour, negative symptoms (lessened emotional expression)
- lifelong tx required
Risk of developing schizophrenia is linked to the use of what drug while brain is developing?
smoking weeeeed
Describe what psychosis is and signs and symptoms
- severe emotional disorder that impairs the mental function of the affected individual to the point of that individual not being able to participates in ADLs
- can be from schizophrenia, depressive, sleep deprivation, and drug-induced psychosis
- Hallmark sign: loss of contact with reality
- Other S/S: hallucinations, delusions, agitation, disorganized thought and behaviour
List 6 different behavioural medications use for MH.
- CNS depressants/hypnotics
- SNRIs*
- SSRIs*
- TCAs**
- MAOI**
- Anti-psychotics
*SNRIs and SSRIS - low risk of OD
**TCAs and MAOIs - high risk of harm with misuse
CNS Depressant medications: Sedatives vs. hypnotics
Sedatives: drugs that have an inhibitory effect on CNS to the degree of reducing nervousness, excitability, and irritability (i.e. benzodiazepines)
- can become a hypnotic if given in a large enough amount
Hypnotics: cause sleep; have a much more potent effect on CNS than sedatives
What are the 3 types of CNS depressants?
1) Barbituates - will cause death in OD
2) Benzodiazepines - rarely causes death in OD
3) Miscellaneous
*mixing benzos with barbituates will cause death
What are barbiturates?
- first introduced in 190, previously were the standard drugs for insomnia and sedation
- habit forming and low therapeutic index - i.e. low dose will work for a short period of time (dependence) - leads to toxicological response (poisoning will lead to CV collapse)
- only a handful commonly used today due to safety issues and efficacy of benzoes
Indications for barbiturates
- sedative
- anticonvulsants
- anesthesia for surgical procedures
What are the four categories of barbituates?
1) Ultra short-acting: anesthesia for short surgical procedures, other uses
2) Short-acting: sedation and control of convulsive conditions
3) Intermediate-acting: sedation and control of convulsive conditions
4) Long-acting: sleep induction, epileptic seizure prophylaxis
Common Barbiturates
- pentobarbital (Nembutol)
- phenobarbital
Effects of barbiturates
- low doses: sedative effects
- can be therapeutic
- high dose: hypnotic effects (also lower RR)
Adverse effects of barbiturates
- notorious enzyme inducers (stimulates liver enzymes that cause metabolism or breakdown of many drugs)
- anesthesia induction
- uncontrollable seizures - phenobarbital coma
- OD can lead to resp depression and then resp arrest
- produces CNS depression (seizure, coma, death)
Barbiturates have a low therapeutic index. This means:
- Low doses are not therapeutic
- The toxic range is narrow
- They are habit forming
- The effective, safe dosage range is narrow.
d. The effective, safe dosage range is narrow.
Benzodiazepines can be classified as either:
1) Sedative-hypnotic
2) Anxiolytic (medication that relieves anxiety)
Benzodiazepines - list long, immediate, and short acting
Long acting: Diazepam (Valium); clonazepam (Klonopin)
Intermediate-acting: Alprazolam (Xanax), lorazepam (Ativan), Temazepam (Restoril)
Short Acting: Midazolam (Versed), Triazolam (Halcion)
Effects and Adverse Effects of benzodiazepines
Effects:
- Calming effect on the CNS
- Useful in controlling agitation and anxiety
- Reduce excessive sensory stimulation, inducing sleep
- Induce skeletal muscle relaxation
Adverse Effects:
- Benzodiazepine’s adverse effects are an overexpression of their therapeutic effects
- Decreased CNS activity, sedation
- cognitive impairment
- Hypotension
- Drowsiness, loss of coordination, dizziness, vertigo, headaches
- Nausea, vomiting, dry mouth, constipation
- fall hazard for elderly persons
- “hangover” effect/daytime sleepiness
- others
Overdose of Benzodiazepines presents as
- Somnolence (sleepiness, lethargy)
- Confusion
- Coma (esp. benzos with alcohol)
- Diminished reflexes
- Do not cause hypotension and respiratory depression unless taken with other CNS depressants
- dangerous when taken with other sedatives or alcohol
What drug can be used to reverse benzodiazepine effects (treatment for withdrawal and dependence)?
Flumazenil - benzodiazepine antagonist, it competitively inhibits the benzodiazepine binding site on GABA
When providing education to the patient on the use of a benzodiazepine medication, the paramedic will include with information:
- These medications have little effect on the normal sleep cycle.
- Using this medication my cause drowsiness the next day
- It is safe to drive while taking this medication.
- These drugs are safe to use with alcohol
B. Using this medication my cause drowsiness the next day
Antidepressant categories
- TCAs - tricyclic antidepressants
- MAOIs - monoamine oxidase inhibitors
-
Second generation antidepressants:
- SSRIs
- SNRIs
Tricyclic antidepressants (TCAs)
- introduced in 1950s, one of the first antidepressants & still considered effective for treating depression (i.e. now considered second line, replaced with SSRIs)
- low therapeutic index (meaning a small amount past therapeutic dose can cause harm/OD)
- rough side effects, usually hard to tolerate
- good choice for some whose depression is resistant to other drugs (so clinicians usually only prescribe TCAs after other drugs have failed to relieve depression)
Indications for TCAs
- depression
- childhood enuresis - bed wetting (imipramine)
- OCD (clomiopramine)
- adjunctive analgesics fro chronic pain conditions such as trigeminal neuralgia (nerve pain from trigeminal nerve)
Effects and Adverse effects of TCAs
- Effects: helps keep more serotonin and NE available to your brain
-
Adverse effects: sedation, impotence, orthostatic hypotension, others
- in older patients: dizziness, postural hypotension, constipation, delayed micturition, edema, muscle tremors
OD on TCAs
- Lethal - 70% to 80% die before reaching the hospital
- CNS and cardiovascular systems are mainly affected
- Death results from seizures or dysrhythmias
Most common TCA is
amitryptyline
Common TCAs
- Amitriptyline (Elavil)
- Amoxapine
- Doxepin
- Imipramine (Tofranil) – for urinary incontinence as well (so they ma ybe on this as well)
- Nortiptyline (Pamelor)
What are Monoamine Oxidase Inhibitors (MAOIs)?
- first type of antidepressant developed
- effective but generally been replaced by antidepressants (because they are safer and cause less side effects)
- cannot be taken with certain meds and foods
- requires diet restrictions as they can cause dangerously high BP when taken with certain foods and meds
Effects of MAOIs
- changes in brain chemistry that are operational in depression
- an enzyme called monoamine oxidase is involved in removing the NTs norepinephrine, serotonin, and dopamine from the brain; MAOIs PREVENT this from happening which makes more of these brain chemicals available to affect changes in both cells and circuits that have been impacted by depression
Adverse Effects of MAOIs
few adverse effects
- orthostatic hypotension (most common)
- tachycardia
- dizziness
- insomnia
- anorexia
- blurred vision
- palpitations
List 4 MAOIs
- Isocarboxazid (Marplan)
- Phenelzine (Nardil)
- Selegiline (Emsam)
- Tranylcypromine (Parnate)
Describe clinical presentation of OD on MAOIs
- Signs of MAOI toxicity are non-specific
- Mild signs: agitation, diaphoresis, tachycardia, mild temp elevation
- Signs of moderate disease: altered mental stasus, tachypnea, vomiting, dysrhythmias, hyperthermia, HTN
- Seizure coma death
How do antipsychotic medications work?
- reduce/relieve symptoms of psychosis (delusions, hallucinations)
- main class of drugs used to treat people with schizophrenia (& for treating serious mental illness, behavioural problems or psychotic disorders)
- have been known as tranquilizers or neuroleptics
How they work:
- block dopamine receptors in the brain (limbic system, basal ganglia); areas associated with emotion, cognitive function, and motor function
- dopamine levels in the CNS are decreased with the result of tranquilizing effect in psychotic patients
Adverse effects of antipsychotic medications
- weight gain
- insomnia
- seizures
- hypotension
- dystonia (involuntary muscle movement)
Common antipsychotic medications (9)
considered atypical antipsychotics (new class) - have fewer side effects than typical antipsychotics (first gen antipsychotics)
- Abilify (aripiprazole)
- Clozaril (clozapine)
- Geodon (ziprasidone)
- Latuda (lurasidone)
- Risperdal (Risperidone)* #1
- Saphris (asenapine)
- Seroquel (Quetiapine)
- Zyprexa (olanzapine)
- Invega (paliperidone)
Clinical presentation of OD on anti-psychotics
- leads to unexplained death and cardiac toxicity
- ECG abnormalities
- QT Elongation (will end up with cardiac standstill)
- neuroleptic malignant syndrome (showing S/S of OD + fever - psychosis mixed with fevers, considered a medical emergency)
How do SSRIs work?
- Selective Serotonin Re-Uptake Inhibitor
- those who are depressed may have serotonin imbalances/dysfunction
- SSRI allows for more available serotonin by blocking reuptake, so more serotonin builds up between neurons (in the synapse) so that messages can be sent correctly
- called “selective” serotonin reuptake inhibitors because they specifically target serotonin
Common SSRIs
- Citalopram (Celexa) - 10 mg to start off, usually the first dx prescription (may also be prescribed for situational depression)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil, Pexeva)
- Sertraline (Zoloft)
- Fluvoxamine (Luvox)
What are SNRIs and how do they work?
- group of meds that may be used in the treatment of depression, anxiety, panic disorder, and some other mood disorders
- usually prescribed if SSRis don’t work
How they work: blocks/delays the re-uptake of 5HT or NE (which are two NTs that are typically released at presynaptic nerves) ⇒ allows for build up of these in the synapse and tends to elevate mood
Common SNRIs
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta) also approved to treat anxiety and certain types of chronic pain
- Venlafaxine (Effexor XR)- Also approved to treat anxiety and panic disorder
Adverse effects of SNRIs
- Sedation
- Impotence
- Orthostatic hypotension
- In older patients: Dizziness, postural hypotension, constipation, delayed micturition edema, muscle tremors
Overdose of SNRIs/SSRIs
SHIVERS acronym: for serotonin syndrome
- Shivering
- Hyperreflexia and Myoclonus: spasmodic jerky contraction of muscles, especially notable in lower extremities
- Increased Temperature:
- Vital Sign Abnormalities: tachycardia, tachypnea, labile BP
- Encephalopathy: mental status changes (agitation, delirium, confusion)
- Restlessness: common due to excess 5HT activity
- Sweating: autonomic response to excess 5HT
- statistically will not lead to death from OD unless +++ doses)
Indications for second generation anti-depressants (SSRIs, SNRIs)
- depression
- bipolar disorder
- obesity
- eating disorders
- OCD
Common miscellaneous second generation anti-depressants
- trazodone (Desyrel, Oleptro)
- bupropion (Wellbutrin)
- nefazodone (Serzone)
- mirtazapine (Remeron)
thiothixene
what class of drug and brand name?
Navane; antipsychotic
Haloperidol
what class of drug and brand name?
Haldol; antipsychotic
Molindone
what class of drug and brand name?
Moban; antipsychotic
Loxapine
What class of drug and brand name?
Loxitane; antipsychotic
What are the two natural meds used for psychological treatment? What are they used for specfically?
1) St. John’s Wort
- used for depression, anxiety, sleep disorders, nervousness
- May cause GI upset, fatigue, dizziness, confusion, dry mouth, photosensitivity
- Severe interactions if taken with MAOIs and SSRIs; many other drug interactions
2) Ginseng
- 3 varieties; has been used for 5000+ years
- stress reduction, improvement in physical endurance and concentration
- may cause elevated BP, chest pain, palpitations, anxiety, insomnia, headache, GI symptoms
- significant toxicity if taken with anticoagulants, immunosuppressants, anticonvulsants and anti-diabetic drugs
What are benzodiazepines?
- CNS depressant
- formerly the most commonly prescribed sedative-hypnotic drugs
- nonbenzodiazepins current more frequently prescribed
- favourable drug effect profiles, efficacy, and safety
Indications for benzodiazepines
- sedation
- sleep induction
- skeletal muscle relaxation
- anxiety relief
- anxiety-related depression
- tx of acute seizure disorders
- treatment of alcohol withdrawal
- agitation relief
- balanced anesthesia
- moderate/conscious sedation
What are two of the most common medications given in pre-hospital setting that affects the GI/GU tract?
benadryl and gravol
Benadryl and Gravol have the same drug components. This means that if you’re having an allergic reaction/nausea, you can take either or. True or False.
True! but this also means that these are contraindications to each other (i.e. if someone was alelrgic and cannot take Benadryl, they cannot take Gravol either)
Common medications for GI/GU system.
1) anti-emetics (anti-emesis)
2) GERD
3) Uterotonics - for females (causes uterus to contract)*
4) Tocolytics - also for uterus (causes uterus to relax)*
*usually used when pregnancy related
Is nausea an illness?
No, usually pre-or post cursor to some other underlying cause/condition
Potential causes of nausea
- neurological (head injuries) - gravol would not work on these patients
- gastroenteritis - in food poisoning patients, you don’t want to suppress the vomiting because its the body’s protective mechanism to rid of toxins
- side effects of other medications
- chest pain
- motion sickness
- fainting
- low blood sugar
- GERD - due to stomach acid coming up
True or false. N//V is a female cardiac symptom
True
Common anti-emetics
- dimenhydrinate (Gravol)
- Ondansetron (Zofran)
As per Nausea/Vomiting Medical Directive (Auxillary), what are the indications, conditions, and contraindications for use of dimenhydrinate?
Indications: Nausea or vomiting
Conditions: Dimenhydrinate - requirements of weight ≥ 25kg and unaltered LOA
Contraindications:
- allergy/sensitivity to dimenhydrinate or other antihistamines
- overdose on antihistamines or anticholinergices or tricyclic antidepressants
As per Nausea/Vomiting Medical Directive (Auxillary), what is the treatment dosage with dimenhydrinate?
- Prior to IV administration, dilute dimenhydrinate (concentration of 50mg/1ml) 1:9 with normal saline or sterile water. If administered IM do not dilute
Would you use Zofran or Gravol for a palliative elderly patient with dementia?
Zofran would be given
components of gravol can cause worsening dementia, hallucinations, depression
What conditions is gravol used for and how does it work?
- used to prevent motion sickness and N/V; radiation therapy; Ménières disease (type of vertigo that causes ringing in ears); vertigo
- Works to relieve N/V by affecting the vomiting centre in the brain (can be triggered by vagal stimulation) and the inner ear
What are the gravol doses for adult/ped/small child/infant and how can it be taken into the body?
- Adult: 50 mg
- Ped: 25 mg
- Small child: 12.5 mg
- Infant: 6.25 mg
- taken via injection or rectally because oral is not working (due to vomiting)
What is Zofran used for and how does it work?
- Anti-emetic; generic name ondansetron
- used to prevent N/V caused by chemo and radiation, or post-surgery
- prescription based
- given to palliative patients via IV or injection at home
How it works: works by blocking serotonin that causes vomiting
Gastroesophageal Reflux Disease (GERD)
- aka indigestion or heart burn (the sphincter opening into the stomach relaxes when it shouldn’t, allowing reflux of acid into the esophagus)
- Regurgitation, pain when lying down, and trouble swallowing and heart burn (burning sensation in your chest or throat cause by acid reflux); indigestion (pain in your upper gut that can feel like gas or bloating)
- typically could present as a cardiac feature so a 12 lead is necessary
- Take tums and if it gets relieved, then it’s GERD and if not, it may be cardiac-related
Describe the escalating dosing levels of medications to suppress acid in GERD.
1) Antacids: used to neutralize or buffer stomach acid (i.e. tums, Mylanta, Alka-Seltzer)
2) H2 Blockers: Blocks the body’s signal to the stomach to produce acid (eg. ranitidine, cimetidine, Zantac, Tagamet)
3) PPIs (Proton Pump Inhibitors): most advanced - blocks the secretion of acid into the stomach (eg. Nexium, Prilosex, Zegerid, Protonix)
What are antacids used for and how do they work?
- OTC med that helps neutralize stomach acid
- can be used to treat excessive stomach acids, gallbladder attacks (excessive gas, cramping)
- component that neutralizes stomach acid: alumnimum hydroxide gel
Common antacids
- Calcium carbonate (Alka-Seltzer, Tums)
- Magnesium hydroxide (Milk of Magnesia)
- OTC:
- Gaviscon - fast acting and long lasting
- Gelusil
- Maalox
- Mylanta
- Rolaids
- Peptobismol
What are H2 blockers used for and how do they work?
- aka H2 receptor antagonists
- used to block body’s signal to produce acid by blocking histamine H2 receptors found on stomach cell surface that release acids (thereby inhibiting certain chemical reactions in these cells so that they are not able to produce as much acid)
- daily prescription required to prevent acid indigestion attacks; flare ups can occur if they miss their med
Common types of H2 Blockers
- fomatidine (Pepcid AC, Pepcid Oral)
- cimetidine (Tagamet, Tagament HB)
- ranitidine (Zantac, Zantac 75, Zantaz Efferdose, Zantac injection, Zantac syrup)
- always prescribed in the generic form
What are proton pump inhibitors (PPIs) used for and how do they work?
- One of the most powerful medications for relieving GERD symptoms & prevent heart burn
- works by blocking and reducing the production of stomach acid & gives any damaged esophageal tissue time to heal
Family name for PPIs and common medications under this category
the RAZOLEs
- omeprazole (Prilosec) - available OTC
- esomeprazole (Nexium) - available OTC
- lansoprazole (Prevacid) - available OTC
- rabeprazole (AcipHex)*
- pantoprazole (Protonix)* - nickname Pantaloc
*most common
What are uterotonics and how do they work?
- medications that increase uterine contraction; could be used for abortion-related calls and associated with bleeding and pain
- includes oxytocin, prostaglandins.misoprostol
- acts on smooth muscles of the uterus (but smooth muscle also found in lungs, esophagus, and stomach so may have effect in these areas as well)
Uterotonic: Oxytocin
Describe what it is and how it works
- a molecule composed of nine peptides that is synthesized in the hypothalamus and secreted from posterior pituitary
- oxytocin attaches to a specific transmembrane receptor and activates it causing uterine smooth muscle contraction
Describe what prostaglandins are and how they work in uterine contractions.
- lipid compounds derived from FA precursors
- prostaglandins are closely associated with labour onset and are released from multiple fatty tissues to start contractions
True or False. Ventolin strictly acts on the smooth muscles of the bronchi and therefore taking ventolin will have no uterotonic effects.
False. Ventolin works on smooth muscles in different body regions include the uterus so taking ventolin not only dilates the bronchial airways but also induces uterine contractions
What is misoprostol and how it is used?
- synthetic medication originall developed to prevent gastric ulceration in patients using long term NSAID Therapy
- street named: the abortion pill
- can be up for early pregnancy
- acts on the post-ganglionic receptors to initiate uterine contractions
- can be used for abortion up to 12 weeks (fertilized egg passes as blood clot), early pregnancy loss (miscarriage and need for expelling embryo/fetus to avoid sepsis), and management of postpartum hemorrhage
What are tocolytics?
meds that relax muscle in pregnancy uterus, may be used in premature labours
Common tocolytics
Mneumonic: It’s not my time
- Indomethecin
- Nefidipine
- Magnesium sulfate - widely used as primary tocolytic agent due to it having similar efficacy to terbutaline with far better tolerance
- Terbutaline - help prevent and slow contractions of uterus; may help delay birth for several hours or days
Others:
- NSAIDs - inhibits synthesis of prostaglandins
- CCBs - disrupts calcium channel function and thus cause smooth muscle relaxation
What is erectile dysfunction and what are the 2 muscles of the penis?
- inadequate blood flow to the penis
- 2 muscles:
- corpus cavernosum
- corpus spongiosum
What are ED dugs used for and how do they work?
- used for those having trouble keeping an erection for sex
- oral meds are first line of treatment
- STRICTLY for sex, not a daily med unless they’re having sex daily
- previously was made for lowering BP but now it’s an ED drug with the side effect of lowering BP
- each ED med works generally the same but has small differences (i.e. how much NO is enhanced, how quickly it takes effect/wears off, other side effects)
How it works:
- enhances effects of nitric oxide (natural chemical in body) that relaxes muscles in the penis allowing for blood flow
- more blood flow to penis during sexual stimulation allows for an erection
ED med use of a contraindication for what drug given by paramedics?
nitro! no nitro for patient is they have taken ED in the last 24 hours because they both drop BP
*also note that people can get chest pain/STEMIs after taking Viagra which may be a contraindication for some resus meds at the hospital so ensure to include in your TOC report
Common ED meds
- sildenafil (Viagra) - takes 1 hour to kick in, lasts 6-12 hours
- vardenafil (Levitra) - takes 30 min to kick in, lasts 6-12 hours
- tadalafil (Cialis) - takes 1-2 hours to kick in, up to 36 hours
- avanafil (Stendra) - takes 15-30 mins to kick in, lasts ~4-6 hours
Side effects of ED meds
- Flushing of the skin
- Headache
- Indigestion
- Blurred vision
- Stuffy/running nose
- Back pain
- An erection that doesn’t go away
- Hearing or vision loss
All^ due to vasodilation
Diarrhea can be described as:
liquid ONLY that is passing through the rectum (NOT LOOSE STOOL)
Causes of sudden diarrhea and treatment
Causes: food poisoning, traveler’s diarrhea, stomach flu
Treatment: none usually; passes without any intervention
Causes of chronic diarrhea and treatment
- celiac disease
- food intolerance/allergy
- milk/soy protein intolerance
- IBS
- medication
Treatment: IV fluids, anti-diarrheal or anti-spasmodic; imodium
What are anti-diarrheal meds?
- meds to stop diarrhea, can be OTC or prescribed
- prescribed meds are typically for more severe cases of diarrhea & those who may have serious health issues related to dehydration from diarrhea
Loperamide - What is it and how does it work?
- aka imodium, an anti-diarrheal
- slows donw how fast contents are moving through intestines & allows more fluid to be absorbed into the body
- helps with producing less diarrhea and more formed stools
- typically better for someone in good health and young in age
- chronic/excess use can cause serious heart problems (arrhythmias or cardiac collapse) or death
OD of loparamide - mechanism and clinical presentation
- Loperamide binds to opioid agonist receptors meaning it can induce opioid-like effects but generally low dependence of abuse & capsules of imodium contain very little loperamide
- risk of adverse effects: CNS depression, respiratory depression, cardiac toxicity
- Cardiac toxicity from OD may be life threatening with QT and QRS prolongation (Torsades, Brugada syndromes, ventricular dysrhythmias, and cardiac arrest)
True or false. Pain in the most common complaint in the pre-hospital setting however it often goes untreated.
True. Often untreated due to bias with how subjective pain is but we always treat it to what they say it is
What is the most common type of pain in prehospital setting?
acute pain
Is pain a disease itself?
No, it is a byproduct of a disease process (a symptom)
Definition of pain
“unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
pain is subjective
What are the different categories/natures that pain can stem from?
- physical
- emotional
- cognitive - depression, depression from cancer
- subjective - so much emotional pain that it manifests as physical pain
- types: acute/chronic
Describe acute pain characteristics.
- identifiable cause
- short duration, protective
- limited tissue damage
- decreased emotional reponse
- causes harm by decreased mobility & energy
-
Goal: control pain so patient can participate in recovery (pain management)
- decreased pain = increased mobility = decreased complications and length of stay in hospital
Describe characteristics of chronic pain
- not protective - serves no purpose
- lasts longer than anticipated
- may or may not have an identifiable cause
- impacts every part of the patient’s life
- high risk of depression and suicide as well as pseudo-addiction (seeking pain relief, not drug seeking such as in FM patients)
What are the 3 types of pain?
1) Cancer pain: considered its own type of pain, full body; may be acute or chronic, constant or episodic, mild or severe
- up to 90% of cancer patients have pain
2) Pain by inferred pathology: any disruption in a cellular way (ex. breaking bones. injuries) - there is a known cause to the pain
3) Idiopathic pain: no known cause but pain or excessive pain is present such as in FM
What is the Wong-Baker pain rating scale?
- Scale characterized by photos of cartoon faces from 0 (No Hurt) -2-4-6-8-10 (Hurts Worst)
- each face represents a different rating of pain
- good for use in pediatrics, language barrier, cognitive impairment, elderly
List the 3 types of analgesia
Benzodiazepines - sedatives
Narcotics
NSAIDS
Why pain management
- improves quality of life
- reduces disability
- promotes early mobility and RTW
- results in less hostpial/office visits
- reduces length of stay, complications
- reduces health care costs
- improves patient satisfaction
Can we as paramedics do a full assessment of pain when patient is in severe pain?
No. Alleviate severe (7-10) pain before proceeding
pain rated >7 needs immediate attention
What is an analgesic?
drug used for pain
Describe the three steps of the analgesic ladder for pain management
Step 1 - Mild to moderate pain: non-opioid (Tylenol or NSAIDs)
Step 2 - Moderate to severe pain: mild opioid - codeine or demoral, or with non-opioids
Step 3 - Severe pain: strong opioids (morphine, fentanyl, oxycontin) with or without non-opioids
What medication is used to counteract OD of analgesic medications?
naloxone/Narcan
Describe what common non-opioid medications are for use as analgesics?
- Tylenol (acetaminophen) - analgesic and anti-pyretic effects
- little to no anti-inflammatory effects
- available OTC and in combination
- Robaxacet: acetaminophen x muscle relaxant (methocarbamol)
- Robaxisal: pain relief from ASA x methocarbamol
- 222’s: ASA x codeine x caffeine
- T3’s - Tylenol x 30 mg of codeine
- T4’s - Tylenol x 60 mg of codeine
- Midol: NSAID x Tylenol (for menstrual cramps)
- can be stacked with ibuprofen to the right doses to create post-op pain management
- Ketorolac IV or IM has the sam therapeutic index as Tylenol and Ibuprofen stacked together (but people will always want IV/IM - optics phenomenon)
How does acetaminophen work and what is it used for? Describe its typical max daily dose in a healthy adult and in elderly/those with liver disease.
- blocks pain impulses peripherally by inhibiting prostaglandin synthesis
- used for mild to mod pain, fever, alternative for those who cannot take aspirin products
- max daily dose in adults for extra strength: 3000mg/day
- max daily dose in elderly or those with liver disease: 2000mg/day
- inadvertent excessive doses may occur when different combination drug products are taken together
OD on tylenol leads to
- will cause hepatic necrosis (hepatotoxicity)
- long term ingestion of large doses causes nephropathy
- recommended antidote: acetylcysteine regimen (NAC)
- if patient survives, likely will have liver and kidney failure requiring dialysis
- risk group: elderly (both male and female); adolescence (statistically female)
Described the different stages and its associated signs and symptoms of acetaminophen toxicity.
- Stage 1: <24h N/V, loss of appetite, pallor, malaise
- Stage 2: 24-72 h RUQ abdo pain, ado tender to palpation
- Stage 3: 72-96h metabolic acidosis, renal failure, coagulopathies, recurring GI sx
- Stage 4: 4-14 d (or longer) recovery slower begins or liver failure progresses and the patient dies
- Give activated charcoal
- Chance of purging stomach within the first 30-60 minutes so chances are good (going CTAS 1)
How do NSAIDs work?
- Work by inhibiting body’s pathways for producing an inflammatory response (inhibiting prostaglandin synthesis)
- interferes with the conversion of arachidonic acid to COX-1/COX-2, therefore prostaglandins and thromboxane A2 are not produced, which leads to decreased pain, inflammation, and fever
- Will not cause resp depression but have chronic complications like gastric ulcers, decreased kidney failure and prolonged bleeding times
- NOT USED FOR LONG TERM, can eat away at stomach lining or else it can burrow into the somtach and cause ulcers
- NSAIDS are not used when patient is on blood thinners as NSAIDs affect the way platelets work and could interfere with normal blood clotting, so taken with blood thinners would further exacerbate the risk of bleeding
Common NSAIDs
- ASA
- Ibuprofen (Advil, Motrin)
- Ketorolac (Toradol) - ONLY BY PRESCRIPTION
What conditions would ASA be used for?
- Specific inflammatory conditions including Kawasaki disease, pericarditis, and rheumatic fever
- Aspirin is used to treat pain, reduce fever or inflammation
- Sometimes used to treat or prevent heart attacks, strokes, and chest pain (angina)
What is Ibuprofen used for and how does it work?
- Brand names: Advil, Motrin
- Medication in the NSAID class that used for treating pain, fever, and inflammation
- Includes painful menstrual periods, migraines, RA
- How it works: reduces hormones that cause inflammation and pain in the body
- As long as they are 12+ y.o. you can give meds via pain management (rmb we are dosing by weight not age)
What is Toradol and how it is used?
- aka Ketorolac, considered a first generation NSAID
- in the family of heterocyclic acetic acid derivatives, used as an analgesic
- used as a short term treatment for moderate to severe pain in adults
- usually used before of after medical procedures/post-op
OD on NSAIDs can lead to what signs and symptoms
- Headache, tinnitus, nausea, comiting, abdo pain, drowsiness, dyspnea,
- Wheezing, pulmonary edema (how you will die), swelling of extremities, rash, itching
- Tachypnea, hyperthermia, confusion, lethargy, coma, cardiac failure, and dysrhythmias
- Abdo pain, vomiting, pulmonary edema, ARDS
- Can make your stomach bleed and cause blood in your stool
What are potential downfalls of analgesic use?
- can cause respiratory depression and hypotension
- may mask progression of symptoms
- can complicate assessment after arrival in receiving facility
What are narcotics and how do they work?
Excessive administration of narcotics can lead to what?
- aka opiates because they either derive from or contain structures similar to opium
- treats moderate to severe pain
- How it works: binds with opiate receptors (which regulate NTs) to block pain receptors in the CNS so pain impulses cannot be transmitted in the brain
- they do not treat the underlying condition
- Excessive administration can lead to respiratory depression
- common practice is to administer narcotics in small multiple doses based on need
Common narcotics used for pain
oxycodone (Oxycontin)
Describe how benzodiazepines are used for pain?
- the most common class of medications used to provide sedations
- Depresses the CNS to sedate the patient, reducing anxiety and overall relaxing them and treating seizures
- can cause anterograde amnesia
Describe how ketamine works for pain?
- aka Ketalar
- causes a state of “dissociation” from their environment
- unlike many analgesics/sedatives, it can stimulate CV system increasing HR and BP
- interferes with pain transmission in the spinal cord
- inhibits formation of nitric oxide, NT involve in pain perception
What is propofol? Describe its use.
- aka Diprivan (brand name)
- a drug that induces nearly immediate state of unconsicousness
- used for transporting patients over long distances and for sedation
- recovery from this state can be rapid with minimal side effects
Describe how Narcan works?
- an opioid antagonist
- binds to opioid receptors and blocks the effects of narcotics
- used to reverse the effects of opioid narcotics
As per the Opioid Toxicity Medical Directive, what are indications, conditions, and contraindications considered prior to use of Naloxone?
Indications: Altered LOC x Respiratory depression x Inability to adequately ventilate OR persistent need to assist ventilations x Suspected Opioid OD
Conditions:
- Age ≥ 24 hours
- Altered LOA
- RR <10 breaths/min
Contraindications: Allergy or sensitivity to naloxone
As per the Opioid Toxicity Medical Directive, what are the treatment doses and clinical considerations for administering Naloxone?
Clinical considerations:
- IV admin only applies to IV certified PCPs
- upfront aggressive management of airway is initial priority
- If no response to initial treatment, consider patching for further doses
- If patient does not respond to airway management and admin of naloxone, glucometry should be considered
- Anticipate combative behaviour follow naloxone admin, paramedics should protect selves and thus recognize importance of gradually titrating (if given IV) to desired clinical effect (i.e. RR ≥ 10, adequate airway and ventilation NOT FULL ALERTNESS)
As per the Analgesic Medical Directive, what are indications, conditions, and contraindications considered prior to use of acetaminophen?
Indications: pain
Conditions: Age ≥12 years, unaltered LOA
Contraindications:
- acetaminophen use within previous 4 hours
- allergy or sensitivity to acetaminophen
- hx of liver disease
- active vomiting
- unable to tolerate oral meds
- suspected ischemic chest pain
As per the Analgesic Medical Directive, provide the appropriate dosing for acetaminophen.
As per the Analgesic Medical Directive, what are indications, conditions, and contraindications considered prior to use of ibuprofen?
Indications: pain
Conditions: Age ≥ 12 years, unaltered LOA
Contraindications:
- NSAID use within previou 6 hours
- allergy or sensitivity to NSAIDs
- patient on anticoagulation therapy
- current active bleeding
- pregnany
- if asthmatic, no prior use of ASA or other NSAIDs
- CVA or TBI in the previous 24 hours
- known renal impairment
- active vomiting
- unable to tolerate oral medication
- suspected ischemic chest pain
As per the Analgesic Medical Directive, what is the proper dosing for ibuprofen
As per the Analgesic Medical Directive, what are indications, conditions, and contraindications considered prior to use of ketorolac?
Indications: pain
Conditions: age ≥ 12 years, unaltered LOA, SBP is normal (normotension)
Contraindications:
- NSAID use within previous 6 hours
- allergy or sensitivity to NSAIDs
- Patient on anticoagulation therapy
- current active bleeding
- Hx of peptic ulcer disease or GI bleed
- Pregnant
- If asthmatic, no prior use of ASA or other NSAIDs
- CVA/TBI in the previous 24 hours
- known renal impairment
- suspected ischemic chest pain
As per the Analgesic Medical Directive, what is the proper dosing for ketorolac?
As per the Analgesic Medical Directive, what are clinical considerations with regards to administration of analgesics?
- Whenever possible, consider co-administration of acetaminophen and ibuprofen
- suspected renal colic patients should routinely be considered for ibuprofen or ketorolac
- IV admin of ketorolac applies only to PCPs who are IV certified
What is an infection?
- invasion of an organism’s body tissues by disease-causing agents, their multiplication and the reaction of host tissues to the infectious agents and the toxins they produce
- a disease/condition caused by a microorganism that releases toxins or invades body tissues
- infectious diseases are also known as transmissible or communicable diseases which are illnesses resulting from an infection
Localized vs. systemic infection
Localized: stays in one area but can turn into a systemic infection if untreated/worsens (ex. thrush)
Systemic: generalized; multiple sites of fast changing organisms (ex. sepsis)
*these are usually more related to bacterial infections rather than viral
What makes an infection worse (i.e. comorbidities)?
- Skin not intact - like bed sores with feces/urine in close contact
- Blood supply impaired - anemics, diabetes
- Neutropenia
- Malnutrition
- Suppression of immune system – hep C, HIV. age
- Diabetes
- Chronic illness
- Advanced age
Types of infection
- bacterial
- viral
- fungal
- parasite-like
can be acute or chronic
What are the two most common bacterial infections that are antibiotic-resistant and commonly found in hospital settings?
1) MRSA - highly transmittable - infection is resistant to most antibiotics (nose, genitals, anything with mucous membranes are easy locations for transmission)
2) VRE - Vancomycin-resistant enterococcus
What are common areas on the body that are prone to infection? Why are they prone to infection?
- Groin, axilla
- Mouth
- Under breast tissue
- Lungs
- Skin
- Blood
Warm, dark, moist areas are GREAT places for bacteria to grow because sunlight does not get to these places and natural sunlight (UVA and UVB) is usually great for sanitation and killing bacteria
How do skin infectious typically look like?
red, puffy, waxy
Cellulitis
inflammation and infection of the skin (can be anywhere on your body)
Ringworm
highly contagious fungal infection causing circular skin rash - caused by parasite worm that burrows under skin and leaves tracks around causing ++itch
cleared with antibiotic cream
Necrotizing fasciitis or gangrene
tissue death (requires amputation to stop infection)
What is varicella and where it is usually found?
- aka chicken pox!
- caused by varicella herpes virus
- typically presents all over body and back
- systemic infection
Herpes simplex virus 1 and 2
- herpes are small clusters of fluid-filled sacs caused by herpes simplex virus
- not treatable, one you have it you always have it (but whether it causes an outbreak/symptoms is different)
- Herpes simplex virus 1 (HSV-1): mostly causes fluid sac clusters on the mouth (transmitted through kissing, oral contact, can happen to kids couple days after birth due to kissing baby)
- Herpes simplex virus 2 (HSV-1): mostly on the genitals (sign of abuse if found on very young children)
- both of these strains can cause herpetic whitlow - painful blisters on fingers caused by HSV
Describe what a yeast infection is and its clinical presentation.
- Candida overgrowth (fungal infection)
- can be in the mouth (tongue, roof of mouth, or throat i.e. thrush)
- childrens who are bottle fed or breast fed may be at risk due to warm moist environments that may not be clean
- can present as skin patches in athlete’s foot, under breast tissue, large folds of skin (obese)
- unpleasant smell
- after prolonged periods, skin under bacterial growth can be raw and red, and become ulcerated
- Treatment: sunlight, washing and drying, use of talcum powder or cornstarch to prevent dampness; if prolonged periods of infection with no treatment, may need antibiotics and fungal creams
Scabies
parasitic infection - essentially lice but burrows under skin and leaves trail of poop
Sites of origin for infections
- Community-associated infection: an infection that is acquired by a person who has not been hospitalized or had a medical procedure (such as dialysis, surgery, catherization) within the past year
-
Healthcare-associated infection: contracted in a hospital or institutional setting that was not present or incubating in the patient on admission to the facility
- More difficult to treat because causative microorganisms are often drug resistant and the most virulent
- Superbugs – not traditionally killed with antibiotics (MRSA most common, VRE) – MRSA requires two negatives in a 6-9 month period to be cleared
- Once you get one of these infections, now you’re at a higher risk of getting another infection
How to prevent infections?
- handwashing
- antiseptics - generally only inhibits growth of microorganisms but does not necessary kill them, applied exclusively to living tissue
- Disinfectants - kills organisms & used only on non-living objects (because it will also kill organi tissue i.e. our skin) - ex. Vyrox
What are the two categories of disinfectants?
- Bactericidal - kills or destroys microorganisms
- Bacteriostatic - retards the growth of microorganisms
Choosing the right medication to treat an infection requires consideration of several important factors. These include:
- Microorganism must be isolated and identified
- Must be able to determine the microorganism’s susceptibility to medication
- Location of the infection must be considered
- Cost
- Potential side effects – N/V/D (most common)
- Patient allergies – highest allergies – penicillin (most common), sulfa
Important factors to consider when following a course of antibiotics
- proper dose and duration of therapy
- avg 7-10 days of therapy (duration of medication use)
- specify time of day to take the drugs to maintain therapeutic levels
- patient must complete entire Rx for it to be considered effective
- if you don’t, it can cause flare ups/worse infections that likely need a new set of antibiotics
- never safe for another time for use (i.e. you can’t save some for another time)
- never share with another person
Define bacteria and types of bacteria
Bacteria: cellular structures are able to survive in a variety of environments
- anaerobic without O2; aerobic: with O2
- gram +ve (tests positive on a strain test) easier to destroy
- gram –ve (tests negative on a strain test) harder to destroy
Shape: cocci (easier to destroy), bacilli (rod shaped bacteria – more area so harder to destroy), spirochetes (spiral shape, worm like – hardest to destroy
What are the 6 types of antibiotics used to inhibit growth of bacteria and treat systemic/localized bacterial infections?
- Aminoglycosides
- Penicillin
- Cephalosporins
- Sulfonamides
- Fluoroquinolones – not a lot of allergies to it, most commonly prescribed
- Macrolides
creams are water based, ointments are oil based
Describe what aminoglycosides are used for
- “Mycins”
- class of antibiotics used to treat serious infections caused by bacteria that either multiply very quickly or are difficult to treat
- typically administered IV
Common aminoglycosides
- Gentamicin (Gentak, Genoptic)
- Tobramycin
- Kanamycin
- Streptomycin
- Neomycin
Side effects of aminoglycosides
- N/V/D
- toxic to kidneys (nephrotoxicity)
- peripheral shock
Describe what penicillin drug category is used for?
- A group of antibiotics which were among the first medications to be effective against many bacterial infections (and saved many lives) - derived from mold
- works indirectly by bursting bacterial cell walls then isolating the burse cells to allow the body to excrete
Indications for use of penicillin
- Gram positive bacteria
- Some gram-negative cocci
- Sexually transmitted disease gonny
- Pneumonia endocarditis
- Skin and wound infections
Common drugs under pencillin category
- penicillin
- amoxicillin
- cloxacillin
Describe what fluoroquinolones are used for?
- aka “oxacin”; most common antibiotic
- antibiotics that are commonly used to treat a variety of illnesses
- used to treat respiratory tract infeictions, UTIs, and STDs
Common fluoriquinolone medications
- Ciprofloxacin
- Levofloxacin (Levoquin) - used to treat microbial pneumonia, gastroenteritis
- Moxifloxacin
- Ofloxacin
- Norfloxacin
Describe the 5 generations of cephalosporins
used to treat RTIs, skin and soft tissue infections in their microbial spectrum
1st gen: potent against gram +ve; mediocre activity against gram -ve
2nd gen: slightly less potent against gram +ve, more active against gram -ve, better cell penetration and increased resistance to beta-lactamases
3rd gen: improved activity against gram-ve and better cell penetration; high binding towards bacterial target
4th gen: improved resistance against beta-lactamases; wider spectrum of activity; high activity against both gram+ve and -ve
5th gen: extended spectrum; approved for tx of critical infections (like hospital acquired pneumonia
Indications for cephalosporins
- Surgical prophylaxis
- Respiratory tract infections
- Skin and soft tissue infections (Cellulitis)
- Bone and joint infections (Osteomyelitis)
- Brain and spinal cord infections (meningitis)
- Blood infections (endocarditis, Urosepsis)
Common cephalosporin drug
polysporin
Side effects of cephalosporins
- Hypersensitivity reactions
- Confusion
- Seizures
- Bleeding
- Nausea vomiting
- Diarrhea
Describe what sulfonamides are and what are they used for?
- functional group based off of several drugs called “sulpha” or “sulfa” drugs
- synthetic (non-antibiotic) antimicrobial agents
- used for bacteriostatic infections, vaginal infections, skin infections, infections secondary to burns
- used for both gram +ve and -ve organisms
- Bactrim or Septra Drugs
Indications for use of Sulfonamides
- vaginal infections
- skin infections
- infections from burns
- malaria
- pneumonia in HIV/AIDS patients
Common sulfonamide drugs
Bactrim
Spectra
Side effects of sulfonamides
- Kidney stones
- Hypersensitivity
- Photosensitivity
- Life threatening skin reactions
- Not to be used in pregnancy or young children
Macrolides
- family name “Romycin”
- a class of antibiotics used to treat respiratory, gastrointestional, and skin infections
- primarily bacteriostatic (inhibits bacterial protein synthesis)
Indications for macrolides
- Aerobic and anaerobic gram-positive cocci
- Chlamydia
- Legionella (causes lung infection)
- Streptococcal and pneumococcal infections
- Uncomplicated skin infections
Common macrolide drugs
- Erythromycin
- Azithromycin (Zithromax)
- Clarithromycin (Biaxin)
What are fungi and what are the indications for anti-fungals?
Fungus: plant-like organisms (molds, yeasts); live as parasites in living tissue or on decaying organic matter
- 50 human pathogens
Indications:
- Intertrigo - rash found in skin folds due to skin-on-skin friction (in often moist areas)
- Yeast infections
- Athletes foot
- Ringworm
- Jock itch
Common anti-fungal medications
- aka anti-mycotic medications to destroy fungus
- Nystatin
- clotrimazole (Canestan)
- miconazole (Monistat)
- fluconazole (Diflucan)
Flagyl
What is the generic name and what is it used for?
used for anaerobic organisms; intra-abdominal and gynecologic infections. protozoal infections (parasitic)
Nitrofurantoin
What is the brand name and what is it used for?
Macrobid
used primarily for UTIs (not part of nitrates)
Vancomycin - what is it used for
number 1 drug used to treat MRSA; natural antibiotic
Cleocin
What is the generic name and what is it used for?
- used to treat serious bacterial infections; strep throat, pneumonia
Why are viruses difficult to kill?
because a virus cannot replicate on its own meaning it needs a host cell; this means that they live inside healthy cells and to kill the virus means you have to kill the healthy cell
What do anti-viral drugs do?
- kill/suppress the virus by destroying virions or inhibiting the ability of viruses to replicate; controlled by current anti-viral therapy used to treat non-HIV viral inections
- influenze viruses
- HSZ, VZV
- Hep A, B, C
Common viruses that cause illness
- Hepatitis viruses
- Herpes viruses
- HIV
- Influenza virus (Flu)
- Respiratory syncytial virus (RSV)
Common anti-viral medications
- acyclovir – for herpetic outbreaks (for herpes) – doesn’t kill it but suppresses it
- Tamiflu - treat influenza
- Peramivir - treat influenza
What is a retrovirus?
A virus that inserts its own DNA into the host DNA
ex HIV
How is HIV/AIDS transmitted?
Transmitted by sexual activity, IV drug use, or perinatally from mother to child (unprotected sex and sharing needles)
What are the 4 stages of an HIV infection
- Stage 1: asymptomatic infection (you don’t know that you have it, asymptomatic for 3-6 months)
- Stage 2: early general symptoms of disease (~8-10 years of on and off symptoms)
- Stage 3: moderate symptoms (around here is dx of AIDS) – stage 3 to 4 is around 1-2 years
- Stage 4: severe symptoms (often leading to death)
Using the sepsis pre-alert tool, a HEWS score of what would be indicative of infection?
5 or up
Types of vaccinations
- live attenuated - weakened form
- inactivated - killed version of the germ that causes a disease
- subunit - contain fragments of protein and/or polysaccharide from the pathogen that will still elicit an immune response
all these activate the immune system producing natural defense
What are viral vaccinations and provide examples.
- protect active immunity in patients before exposure or to control epidemics of viral disease in a community
- Cervical cancer, chicken pox, hepatitis A/B, Avian influenzas (H1N1), Rabies
How do influenza vaccinations work?
- Changes year to year
- Predictated strains
- Most years can be mistargeted
- vaccine uses inactivated virus
- Everyone ≥6 months old is eligible
Provide two examples of bacterial vaccines
- contain killed or attenuated bacteria that activate the immune system
- pneumococcal vaccine (for pneumonia)
- meningococcal vaccine (for meningitis)
Define toxicology
- the study of chemicals that cause problems for living things (anything that is organic)
- chemicals may be natural or synthetics
- can range from mild skin irritation to death
What is a toxidrome?
- a toxic syndrome caused by a dangerous level of toxins in the body; can be a drug, poison
- often the consequence of a toxin overdose, exposure, anything that is toxic to organic tissue
- there are many forms related to drug categories such as:
- Opiate toxidrome
- Hallucinogenic toxidrome
- Cholinergic/anticholinergic toxidrome
- Sedative/hypnotic toxidrome
- Sympathomimetic toxidrome
Define drug vs poison
Drug: a substance that has a therapeutic window and effect when given in the appropriate dose and circumstance
Poison: a substance that is toxic by nature, no matter how it gets into the body or how much is taken (i.e. poison ivy, anthrax, arsenic)
What does it mean “the dose makes the poison”?
means that a substance that contains toxic properties can cause harm only if it occurs in a high enough concentration; in other words, some things are not toxic in small amounts but when too much is ingested, can become toxic
ex. apple seeds, pear seeds
Intentional vs unintentional drug abuse
Intentional: OD-ing with purpose or intimate crime (OD-ing someone else)
Unintentional: can occur in many ways like children who mistakenly put poison in their mouths
Define drug abuse vs drug addiction
Drug abuse: use of drugs that causes harm to the user or to others affected by the user
Drug addiction: chronic disorder characterized by compulsive use of a substance (illicit substances or substances that you no longer need but still use like percocets)
Define the following terms:
Habituation
Physical dependence
Psychological dependence
Tolerance
Withdrawal Syndrome
Habituation: psychological dependence on a drug or drugs
Physical dependence: a physiological state of adaptation to a drug
Psychological dependence: emotional state of craving a drug to maintain well being
Tolerance: physiological adaptation to drug effects
Withdrawal Syndrome: occurs after the abrupt cessation or decrease of a drug
Potentiation vs Synergism
Potentiation: enhancement of the effect of one drug by taking it with another drug
Synergism: action of two substances in which the effects are greater than the independent effects (1+1 = 3)
- ex. alcohol x lorazepam x joint = rohypnol effect
How would you assess someone who has overdose?
- How much was taken, injected, absorbed or inhaled?
- What else was taken
- Has the patient vomited or aspirated
- Why was the substance taken?
- What was ingested, when, how much
- Did you drink alcohol?
- Have you attempted to throw up?
- What is your weight?
List the way drugs or a toxidrome can enter the body
- Ingestion
- Inhalation
- Absoprtion
- Injection - including animal bites and stings
What is food poisoning and what can it be caused by?
- unintentional toxicological response
- can be caused by bacteria, viruses, or toxins
- 3 types: salmonella (poulty), listeria (lunch meats, soft cheese), toxoplasma (food that isn’t stored properly, red meats)
Signs and symptoms of food poisoning
N/V/D, abdo pain, facial flushing, respiratory distress, melena
What is CO poisoning and what is the treatment for it?
- a colourless, odorless, tasteless gas that displaces oxygen and prevents it from getting to the tissues causing suffocation at a cellular level
- treatment: hyperbaric chamber (THE ONLY TX)
Stages and side effects of CO poisoning
Mild: slight headache, N/V, fatigue
Moderate: severe headache, confusion, drowsiness, fast HR
Extreme: unconscious, convulsions, cardiorespiratory failure, death
*they may also have a cherry red look, bounding pulse, dilated pupils, and cyanosis
Toxidromes caused by inhalation of toxic gases, vapors, fumes, etc are absorbed where in the body?
capillary-alveolar membrane in the lungs
Toxidromes caused by absorption
- via skin contact & absoprtion occurs through capillaries in the skin
- ex. poison ivy, oak, sumac, organophosphates, patches (nitro, nicotine, fentanyl)
*
Signs and symptoms of cholinergic toxidrome?
- excessive salivation, lacrimation, diaphoresis, abdominal cramps, nausea, vomiting, diarrhea, altered mental status (cholinergic response)
- SLUDGE DUMBBELLS
Where in the body does absorption occur in toxidromes caused by ingestion?
absorption occurs in the stomach and small intestine
Toxidromes caused by injection enter the body through what?
break in the skin
How do you know some one is suffering from food poisoning?
If you arrive on scene and two or more people are suffering the same malaise symptoms, you can speculate CO or food poisoning
When you arrive on scene, how do you know the difference between CO and food poisoning?
There are stages with CO poisoning while with food poisoning it’s just one stage
Is anaphylaxis a toxicological response?
Yes. ex. insect stings would be a considered toxidrome via injection
Signs and symptoms of allergic reactions
localized pain, redness, swelling, skin wheal; may progress to angioedema (swelling of face) and airway closure
What is a common source of accidental poisoning in children?
Ingestion of poisonous plants
Who is at risk for overdosing on prescription medications?
Elderly - forgotten if they’ve already taken their pills
Children - who think its candy
What is the difference between opioid and opiate?
Opiate: natural drug derived from opium
Opioid: non-opioid-derived synthetics
List commonly abused substances.
- Opioids
-
Stimulants
- Methamphetamine
- Methylenedioxymethamphetamine (MDMA, ecstasy)
- Cocaine
- methylphenidate (Ritalin)
-
Depressants
- Benzodiazepines
- Barbiturates
- Marijuana
- Alcohol
- Anabolic steroids
- Dextromethorphan
- Lysergic acid diethylamide (LSD)
- Nicotine
- Phencyclidine (PCP)
Common opioids
- opium
- heroin( diacetylmorphine)
- hydrocodone
- meperidine
- morphine
- codeine
- hydromorphone
- oxycodone
- propoxyphene
- methadone
As per the Moderate to Severe Allergic Reaction Medical Directive, what are the indications, conditions, and contraindications for providing epinephrine and diphenhydramine?
Indications: exposure to a probably allergen AND S/S of moderate to severe allergic reaction (including anaphylaxis)
Conditions:
- Epinephrine: for anaphylaxis only
- Diphenhydramine: weight ≥25kg
Contraindications:
- Epinephrine: allergy or sensitivity to epinephrine
- Diphenhydramine: allergy or sensitivity to diphenhydramine
As per the Moderate to Severe Allergic Reaction Medical Directive, what is the accurate dosing for epinephrine?
Epinephrine administration takes priority over IV access
As per the Moderate to Severe Allergic Reaction Medical Directive, what is the accurate dosing for diphenhydramine?
Opium and heroin are considered Schedule ____ drugs. Most others are Schedule ___ due to their high potential for abuse
I; II
Opioids are often abused why?
due to their ability to produce euphoric state
What effect does opioid have on the body and what is it normally used for?
Effects:
- produce analgesia, drowsiness, euphoria, tranquility, other mood alterations
- affect areas outside teh CNS - Skin, GI and GU tract
Normally used to: relieve pain, reduce cough, relieve diarrhea, and induce anesthesia
Adverse effects of opioids
CNS:
- diuresis
- miosis - pinpoint pupils
- convulsions
- N/V
- respiratory depression
Non-CNS:
- hypotension
- constipation
- urinary retention
- flushing of the face, neck, and upper thorax
- sweating, urticaria, and pruritis
Identify the peak period, duration, and S/S of opioid drug withdrawal.
- Peak period: 1-3 days
- Duration: 5-7 days
- Signs: drug seeking, mydriasis (dilated pupils), diaphoresis, rhinorrhea, lacrimation, diarrhea, elevated BP and HR
- Symptoms: intense desire for drug, muscle cramps, arthralgia, anxiety, N/V, malaise
Treatment for opioid drug withdrawal
- Block opioid receptors so that use of opioid drugs does not produce euphoria
- Naltrexone—an opioid antagonist
- Vivitrol—injectable form of naltrexone
- Naloxone combined with buprenorphine (Subutrex) or used alone (Suboxone)
What do stimulants do?
- elevate mood
- reduce fatigue
- increase alertness
- invigorate aggressiveness
What affects do depressants have and what are they used for?
- drugs that relieve anxiety, irritability, and tension
- used to treat seizure disorders and induce anesthesia
- two main pharmacologic classes:
- benzodiazepines (flunitrazepam)
- barbiturates
- marijuana (pot, grass, weed)
Adverse effects of depressants
CNS: drowsiness, sedation, loss of coordination, dizziness, blurred vision, headaches, and paradoxical reactions
Gastrointestinal: N/V, constipation, dry mouth, and abdominal cramping
Pruritus and skin rash
“Amotivational” syndrome
Identify the peak period and duration of withdrawal from short-acting and long-acting depressants.
Peak Period:
- 2-4 days for short acting drugs
- 4-7 days for long acting drugs
Duration:
- 4-7 days for short acting drugs
- 7-12 days for long acting drugs
Signs/Symptoms of depressants withdrawal
Signs: increased psychomotor activity, agitation, hyperthermia, diaphoresis, delirium, convulsions, elevated BP & HR, temperature, and others
Symptoms: anxiety, depression, euphoria, incoherent thoughts, hostility, grandiosity, disorientation, hallucinations, suicidal thoughts
Treatment of depressant withdrawal
tapering of the drug over a course of 7-10 or 10-14 ays
What is alcohol and what is it used for?
- aka ethanol (EtOH)
- causes CNS depression by dissolving in lipid membranes in the CNS
- few legitimate uses of ethanol and alcoholic beverages
- used as a solvent for many drugs
Effects of Ethanol on the body and withdrawal S/S
- CNS depression
- Respiratory stimulation or depression
- Vasodilation, producing warm, flushed skin
- Increased sweating
- Diuretic effects
Withdrawal S/S:
- withdrawal seizures
- delirium tremens (dehydrations and electrolyte imbalance)
- tremors, diaphoresis, hallucinations
Treatment for alcholism
- disulfiram (Antabuse)
- Acetaldehyde syndrome (accumulation of acetaldehyde because
- naltrexone
- acamprosate (Campral) - Newest treatment
- Counseling
- Individual
- Alcoholics Anonymousa
