Section 5.3: Complete AV Pharmacology Flashcards
Adrenaline – Presentation/s
- 1mg in 1mL glass ampoule (1:1000)
- 1mg in 10mL glass ampoule (1:10000)
Adrenaline – Pharmacology
A naturally occurring alpha and beta-adrenergic stimulant
Actions:
- Increases HR by increasing SA node firing rate (Beta 1)
- Increases conduction velocity through the A-V node (Beta 1)
- Increases myocardial contractility (Beta 1)
- Increases the irritability of the ventricles (Beta 1)
- Causes bronchodilation (Beta 2)
- Causes peripheral vasoconstriction (Alpha)
Adrenaline – Metabolism
- By monoamine oxidase and other enzymes in the blood, liver and around nerve endings. Excreted by the kidneys
Adrenaline – Primary emergency indication/s
- Cardiac arrest – VF / VT, Asystole or PEA
- Inadequate perfusion (cardiogenic or non-cardiogenic / non-hypovolaemic)
- Bradycardia with poor perfusion
- Anaphylaxis
- Severe asthma – imminent life threat not responding to nebulised therapy, or unconscious with no BP
- Croup
Adrenaline – Contraindication/s
- Hypovolaemic shock without adequate fluid replacement
Adrenaline – Precaution/s
Consider reduced doses for:
- Elderly / frail Pts
- Pts with cardiovascular disease
- Pts on monoamine oxidase inhibitors
- Higher doses may be required for Pts on beta blockers
Adrenaline – Route/s of administration
- Nebulised
- IM
- IV
- IV infusion
- ETT
- IO
Adrenaline – Side effects
- Sinus tachycardia
- Supraventricular arrhythmias
- Ventricular arrhythmias
- Hypertension
- Pupillary dilation (mydriasis)
- May increase size of the Myocardial Infarction
- Feeling of anxiety / palpitations in the conscious Pt
Adrenaline – Special notes
- IV Adrenaline should be reserved for life threatening situations
Adrenaline – Onset, Peak & Duration times (IV & IM)
IV effects:
- Onset: 30sec
- Peak: 3 – 5min
- Duration: 5 – 10min
IM effects:
- Onset: 30 – 90sec
- Peak: 4 – 10min
- Duration: 5 – 10min
Aspirin – Presentation/s
- 300mg chewable tablets
- 300mg soluble or water dispersible tablets
Aspirin – Pharmacology
An analgesic, antipyretic, anti-inflammatory and anti-platelet aggregation agent
Actions:
- To minimize platelet aggregation and thrombus formation in order to retard the progression of coronary artery thrombosis in Acute Coronary Syndrome
- Inhibits the synthesis of prostaglandins – anti-inflammatory actions
Aspirin – Metabolism
- Converted to salicylate in the gut mucosa and liver. Excreted mainly by the kidneys.
Aspirin – Primary emergency indication/s
- Acute Coronary Syndrome
Aspirin – Contraindication/s
- Hypersensitivity to aspirin / salicylates
- Actively bleeding peptic ulcers
- Bleeding disorders
- Suspected dissecting aortic aneurysm
- Chest pain associated with psychostimulant OD if SBP > 160mmHg
Aspirin – Precaution/s
- Peptic ulcer
- Asthma
- Pts on anticoagulants
Aspirin – Route/s of administration
- Oral
Aspirin – Side effects
- Heartburn
- Nausea
- Gastrointestinal bleeding
- Increased bleeding time
- Hypersensitivity reactions
Aspirin – Special notes
- Aspirin is C/I for use in acute febrile illness in children and adolescents.
- The anti-platelet effects of Aspirin persist for the natural life of platelets.
Aspirin – Onset, Peak & Duration times
- Onset: N/A
- Peak: N/A
- Duration: 8 – 10days
Ceftriaxone – Presentation/s
- 1g sterile powder in a glass vial
Ceftriaxone – Pharmacology
- Cephalosporin antibiotic
Ceftriaxone – Metabolism
- Excreted unchanged in urine (33% - 67%) and in bile
Ceftriaxone – Primary emergency indication/s
- Suspected meningococcal septicaemia
- Severe sepsis (consult only)
Ceftriaxone – Contraindication/s
- Allergy to Cephalosporin antibiotics
Ceftriaxone – Precaution/s
- Allergy to Penicillin antibiotics
Ceftriaxone – Route/s of administration
- IV (preferred)
- IM (if IV access unavailable)
Ceftriaxone – Side effects
- Nausea
- Vomiting
- Skin rash
Ceftriaxone – Special notes
Usual dose:
- Adult 1g
- Child 50mg / kg (max. 1g)
Ceftriaxone IV must be made up to 10mL using sterile water and dose administered over 2min
Ceftriaxone IM must be made up to 4mL using 1% Lignocaine and dose administered in lateral upper thigh
Ceftriaxone – Onset, Peak & Duration times
IM / IV effects:
- Onset: N/A
- Peak: N/A
- Duration: N/A
Dextrose 10% – Presentation/s
- 25g in 250mL infusion soft pack
Dextrose 10% – Pharmacology
A slightly hypertonic crystalloid solution
Composition:
- Sugar – 10% dextrose
- Water
Actions:
- Provides a source of energy
- Supplies body water
Dextrose 10% – Metabolism
Dextrose:
- Broken down in most tissues
- Stored in the liver and muscle as glycogen
Water:
- Distributed throughout total body water, mainly in the extracellular fluid compartment
- Excreted by the kidneys
Dextrose 10% – Primary emergency indication/s
- Diabetic hypoglycaemia (BGL analysis
Dextrose 10% – Contraindication/s
- Nil of significance in the above indication
Dextrose 10% – Precaution/s
- Nil of significance in the above indication
Dextrose 10% – Route/s of administration
- IV infusion
Dextrose 10% – Side effects
- Nil of significance in the above indication
Dextrose 10% – Special notes
Officially - none, however (see Special Notes under Hypoglycaemia CPG A0702):
- Ensure IV is patent before administering Dextrose. Extravasation of Dextrose can cause tissue necrosis.
- All IVs should be well flushed before and after Dextrose administration (minimum 10mL Normal Saline).
- Further dose of Dextrose 10% may be required in some hypoglycaemic episodes. Consider consultation if BGL remains
Dextrose 10% – Onset, Peak & Duration times
IV infusion effects:
- Onset: 3min
- Peak: N/A
- Duration: Depends on severity of hypoglycaemic episode
Fentanyl – Presentation/s
- 100mcg in 2mL glass ampoule
- 200mcg in 1mL glass vial (IN use only)
- 600mcg in 2mL glass vial (IN use only)
Fentanyl – Pharmacology
A synthetic opioid analgesic
Actions:
CNS effects:
- CNS depression – leading to analgesia
- Respiratory depression – leading to apnoea
- Dependence (addiction)
Cardiovascular effects:
- Decreases conduction velocity through the AV node
Fentanyl – Metabolism
- By the liver; excreted by the kidneys
Fentanyl – Primary emergency indication/s
- Sedation to facilitate intubation
- Sedation to maintain intubation
- Drug facilitated intubation
- Analgesia – IV / IN
Fentanyl – Contraindication/s
- Known hypersensitivity
- IV Amiodarone
Fentanyl – Precaution/s
- Elderly / frail patients
- Impaired renal / hepatic function
- Respiratory depression, eg COPD
- Current asthma
- Pts on monoamine oxidase inhibitors
- Known addiction to opioids
- Rhinitis, rhinorrhea or facial trauma (IN route)
- Oral Amiodarone
Fentanyl – Route/s of administration
- IV
- IN
Fentanyl – Side effects
- Respiratory depression
- Apnoea
- Rigidity of the diaphragm and intercostal muscles
- Bradycardia
Fentanyl – Special notes
- Fentanyl is a Schedule 8 drug under the Poisons Act and its use must be carefully controlled with accountability and responsibility
- Respiratory depression can be reversed with Naloxone
- 100mcg Fentanyl is equivalent in analgesic activity to 10mg Morphine
Fentanyl – Onset, Peak & Duration times
IV effects:
- Onset: Immediate
- Peak:
- Duration: 30-60min
IN effects:
- Onset: N/A
- Peak: 2min
- Duration: N/A
Glucagon – Presentation/s
- 1mg (IU) in 1mL hypokit
Glucagon – Pharmacology
A hormone normally secreted by the pancreas
Actions:
- Causes an increase in blood glucose concentration by converting stored liver glycogen to glucose
Glucagon – Metabolism
- Mainly by the liver, also by the kidneys and in the plasma
Glucagon – Primary emergency indication/s
- Diabetic hypoglycaemia (BGL
Glucagon – Contraindication/s
- Nil of significance in the above indication
Glucagon – Precaution/s
- Nil of significance in the above indication
Glucagon – Route/s of administration
- IM
Glucagon – Side effects
- Nausea and vomiting (rare)
Glucagon – Special notes
- Not all Pts will respond to Glucagon, eg those with inadequate glycogen stores in the liver (alcoholics, malnourished)
Glucagon – Onset, Peak & Duration times
IM effects:
- Onset: 5min
- Peak: N/A
- Duration: 25min
Glyceryl Trinitrate (GTN) – Presentation/s
- 0.6mg tablets
- Transdermal GTN Patch (50mg 0.4mg / hr release)
Glyceryl Trinitrate (GTN) – Pharmacology
Principally, a vascular smooth muscle relaxant
Actions:
- Venous dilatation promotes venous pooling and reduces venous return to the heart (reduces preload)
- Arterial dilatation reduces systemic vascular resistance and arterial pressure (reduces afterload)
The effects of the above are:
- Reduced myocardial 02 demand
- Reduced systolic, diastolic and mean arterial blood pressure, whilst usually maintaining coronary perfusion pressure
- Mild collateral coronary arterial dilatation may improve blood supply to ischaemic areas of myocardium
- Mild tachycardia secondary to slight fall in blood pressure
- Preterm labour: Uterine quiescence in pregnancy
Glyceryl Trinitrate (GTN) – Metabolism
- By the liver
Glyceryl Trinitrate (GTN) – Primary emergency indication/s
- Chest pain with ACS
- Acute LVF with SOB and audible fine crackles (bases, mid-zones or full field)
- Hypertension associated with ACS
- Autonomic dysreflexia
- Preterm labour (consult)
Glyceryl Trinitrate (GTN) – Contraindication/s
- Known hypersensitivity
- Systolic blood pressure
- Systolic blood pressure
- Sildenafil Citrate (Viagra) or Vardenafil (Levitra) administration in the previous 24hr or Tadalafil (Cialis) administration in the previous 4 days (PDE5 inhibitors)
- Heart rate > 150bpm
- Bradycardia HR
- VT
- Inferior STEMI with systolic BP
- Right ventricular MI
Glyceryl Trinitrate (GTN) – Precaution/s
- No previous administration
- Elderly Pts
- Recent MI
- Concurrent use with other tocolytics
Glyceryl Trinitrate (GTN) – Route/s of administration
- SL
- Buccal
- Transdermal
- Infusion (inter-hospital transfer only)
Glyceryl Trinitrate (GTN) – Side effects
- Tachycardia
- Hypotension
- Headache
- Skin flushing (uncommon)
- Bradycardia (occasionally)
Glyceryl Trinitrate (GTN) – Special notes
Storage:
- GTN is susceptible to heat and moisture. Make sure that tablets are stored in their original light resistant, tightly sealed bottles. The foil pack of the patches should be intact.
- Tablets should be discarded and replaced after 1 month
- Patches should be discarded prior to the use-by date
- Do not administer Pt’s own medication as its storage may not have been in optimum conditions or it may have expired
History taking:
- Since both men and women can be prescribed Sildenafil Citrate (Viagra) or Vardenafil (Levitra) or Tadalafil (Cialis), all Pts should be asked if and when they last had the drug to determine if GTN is C/I
- Tadalafil (Cialis) may also be prescribed to men for Rx of benign prostatic hypertrophy. This is a new indication for the drug and may lead to an increased number of Pts under this Rx regimen
Inter-hospital transfer:
- GTN by IV infusion may be required for an inter-hospital transfer as per the treating doctor’s orders
- The IV dose is to be prescribed and signed by the referring hospital medical officer. Infusions usually run in the range of 5mcg / min to 200mcg / min and increased 3 – 5mcg / min
Glyceryl Trinitrate (GTN) – Onset, Peak & Duration times
IV effects:
- Onset: 30sec – 1min
- Peak: 3 – 5min
- Duration: 15 – 30min
S/L effects:
- Onset: 30sec – 2min
- Peak: 5 – 10min
- Duration: 15 – 30min
Transdermal effects:
- Onset: Up to 30min
- Peak: 2hr
- Duration: N/A
Ipratropium Bromide – Presentation/s
- 250mcg in 1mL nebule or polyamp
Ipratropium Bromide – Pharmacology
Anticholinergic bronchodilator
Actions:
- Allows bronchodilatation by inhibiting cholinergic bronchomotor tone (ie blocks vagal reflexes which mediate bronchoconstriciton
Ipratropium Bromide – Metabolism
- Excreted by the kidneys
Ipratropium Bromide – Primary emergency indication/s
- Severe respiratory distress associated with bronchospasm
Ipratropium Bromide – Contraindication/s
- Known hypersensitivity to Atropine or its derivatives
Ipratropium Bromide – Precaution/s
- Glaucoma
- Avoid contact with eyes
Ipratropium Bromide – Route/s of administration
- Nebulised (in combination with Salbutamol)
Ipratropium Bromide – Side effects
- Headache
- Nausea
- Dry mouth
- Skin rash
- Tachycardia (rare)
- Palpitations (rare)
- Acute angle closure glaucoma secondary to direct eye contact (rare)
Ipratropium Bromide – Special notes
- There have been isolated reports of ocular complications (dilated pupils, increased intraocular pressure, acute angle glaucoma, eye pain) as a result of direct eye contact of Ipratropium Bromide formulations
- The nebuliser mask must therefore be fitted properly during inhalation and care taken to avoid Ipratropium Bromide solution entering the eyes
- Ipratropium Bromide must be nebulised in conjunction with Salbutamol and is to be administered as a single dose only
Ipratropium Bromide – Onset, Peak & Duration times
Nebulised effects:
- Onset: 3 – 5min
- Peak: 1.5 – 2hr
- Duration: 6hr
Lignocaine 1% (IM administration) – Presentation/s
- 50mg in 5mL amp (1%)
Lignocaine 1% (IM administration) – Pharmacology
A local anaesthetic agent
Actions:
- Prevents initiation and transmission of nerve impulses causing local anaesthesia (1% solution)
Lignocaine 1% (IM administration) – Metabolism
- By the liver (90%)
- Excreted unchanged by the kidneys (10%)
Lignocaine 1% (IM administration) – Primary emergency indication/s
- Dilutent for Ceftriaxone for IM administration in suspected meningococcal disease
Lignocaine 1% (IM administration) – Contraindication/s
- Known hypersensitivity
Lignocaine 1% (IM administration) – Precaution/s
- When using Lignocaine 1% as dilutent for IM Ceftriaxone, it is important to rule out inadvertent IV administration due to potential CNS complications
Lignocaine 1% (IM administration) – Route/s of administration
- IM (1% solution with Ceftriaxone only)
Lignocaine 1% (IM administration) – Side effects
- Nil – unless inadvertent IV administration
Lignocaine 1% (IM administration) – Special notes
N/A
Lignocaine 1% (IM administration) – Onset, Peak & Duration times
IM effects:
- Onset: Rapid
- Peak: N/A
- Duration: 1 – 1.5hr
Methoxyflurane – Presentation/s
- 3mL glass bottle
Methoxyflurane – Pharmacology
- Inhalational analgesic agent at low concentrations
Methoxyflurane – Metabolism
- Excreted mainly by the lungs
- By the liver
Methoxyflurane – Primary emergency indication/s
- Pain relief
Methoxyflurane – Contraindication/s
- Pre-existing renal disease / renal impairment
- Concurrent use of tetracycline antibiotics
- Exceeding total dose of 6mL in a 24hr period
Methoxyflurane – Precaution/s
- The Penthrox inhaler must be hand-held by the Pt so that if unconsciousness occurs it will fall from the Pt’s face. Occasionally the operator may need to assist but must continuously assess the level of consciousness
- Pre-eclampsia
- Concurrent use with Oxytocin may cause hypotension
Methoxyflurane – Route/s of administration
- Self administration under supervision using the hand held Penthrox inhaler
Methoxyflurane – Side effects
- Drowsiness
- Decrease in blood pressure and bradycardia (rare)
- Exceeding the maximum total dose of 6mL in a 24hr period may lead to renal toxicity
Methoxyflurane – Special notes
- The maximum initial priming dose for Methoxyflurane is 3mL. This will provide approximately 25min of analgesia and may be followed by one further 3mL dose once the initial dose is exhausted if required.
- Analgesia commences after 8 – 10 breaths and lasts for approximately 3 – 5min once discontinued
- Do not administer in a confined space. Ensure adequate ventilation in ambulance.
Methoxyflurane – Onset, Peak & Duration times
- Onset: After ~ 8 – 10 breaths
- Peak: N/A
- Duration: Continuous use ~25min; Once discontinued ~ 3 – 5min
Metoclopramide – Presentation/s
- 10mg in 2mL polyamp
Metoclopramide – Pharmacology
Antiemetic
Actions:
- Accelerates gastric emptying and peristalsis
- Dopamine receptor antagonist
Metoclopramide – Metabolism
- By the liver; excreted by the kidneys
Metoclopramide – Primary emergency indication/s
- Nausea / vomiting associated with:
- Chest pain / discomfort of a cardiac nature
- Opioid administration for pain
- Cytotoxic or radiotherapy
- Previously diagnosed migraine
- Severe gastroenteritis
- Prophylaxis:
- Awake, spinal immobilised Pts
- Eye trauma
Metoclopramide – Contraindication/s
- Children
- Suspected bowel obstruction or perforation
- Gastrointestinal haemorrhage
Metoclopramide – Precaution/s
- Undiagnosed abdominal pain
- Adolescents (
- Administer slowly over 1min to minimise risk of extrapyramidal reactions
Metoclopramide – Route/s of administration
- IV
- IM
Metoclopramide – Side effects
- Drowsiness
- Lethargy
- Dry mouth
- Muscle tremor
- Extrapyramidal reactions (usually the dystonic type)
Metoclopramide – Special notes
- Not effective for established motion sickness.
- Not effective for nausea prophylaxis in the setting of opioid administration.
Metoclopramide – Onset, Peak & Duration times
IV effects:
- Onset: 1 – 3min
- Peak: N/A
- Duration: 10 – 30min
IM effects:
- Onset: 10 – 15min
- Peak: N/A
- Duration: 1 – 2hr
Midazolam – Presentation/s
- 5mg in 1mL glass ampoule
- 15mg in 3mL glass ampoule
Midazolam – Pharmacology
Short acting CNS depressant
Actions:
- Anxiolytic
- Sedative
- Anti-convulsant
Midazolam – Metabolism
- By the liver; excreted by the kidneys
Midazolam – Primary emergency indication/s
- Status epilepticus
- Sedation to enable intubation (RSI / IFS)
- Post intubation sedation
- Sedation to enable synchronized cardioversion
- Sedation in the agitated Pt (including Pts under the Mental Health Act 2014)
- Sedation in psychostimulant OD
Midazolam – Contraindication/s
- Known hypersensitivity to benzodiazepines
Midazolam – Precaution/s
- Reduced doses may be required for the elderly / frail, Pts with chronic renal failure, CCF or shock
- The CNS depressant effects of benzodiazepines are enhanced in the presence of narcotics and other tranquillisers including alcohol
- Can cause severe respiratory depression in Pts with COPD
- Pts with myasthenia gravis
Midazolam – Route/s of administration
- IM
- IV
- IV infusion
Midazolam – Side effects
- Depressed level of consciousness
- Respiratory depression
- Loss of airway control
- Hypotension
Midazolam – Special notes
N/A
Midazolam – Onset, Peak & Duration times
IV effects:
- Onset: 1 – 3min
- Peak: 10min
- Duration: 20min
IM effects:
- Onset: 3 – 5min
- Peak: 15min
- Duration: 30min
Misoprostol – Presentation/s
- 200mcg tablet
Misoprostol – Pharmacology
A synthetic prostaglandin
Actions:
- Enhances uterine contractions
Misoprostol – Metabolism
- Converted to active metabolite misoprostol acid in the blood
- Metabolised in the tissues and excreted by the kidneys
Misoprostol – Primary emergency indication/s
- PPPH
Misoprostol – Contraindication/s
- Allergy to prostaglandins
- Exclude multiple pregnancy before drug administration
Misoprostol – Precaution/s
- Hx of asthma
Misoprostol – Route/s of administration
- Oral
Misoprostol – Side effects
- Hyperpyrexia
- Shivering
- Abdominal pain
- Diarrhoea
Misoprostol – Special notes
- Side effects are more likely with > 600mcg oral dose
Misoprostol – Onset, Peak & Duration times
Oral effects:
- Onset: 8 – 10min
- Peak: N/A
- Duration: 2 – 3hr
Morphine – Presentation/s
- 10mg in 1mL glass ampoule
Morphine – Pharmacology
An opioid analgesic
Actions:
CNS effects:
- CNS depression (leading to analgesia)
- Respiratory depression
- Depression of cough reflex
- Stimulation (changes of mood, euphoria or dysphoria, vomiting, pin-point pupils)
- Dependence (addiction)
Cardiovascular effects:
- Vasodilatation
- Decreases conduction velocity through the AV Node