The emergency drug kit

Question 1

Role of the vet tech when it comes to the emergency drug kit

Answer 1

May vary between clinics
Must be within provincially legislated scope of practice
Maintain a fully stocked readily accessible emergency drug tool kit

Question 2

What needs to be in an emergency drug kit as of the SVMA standards

Answer 2

Practice standard 7- pharmacy
Companion animal standard emergency drugs are readily available as follows
Epinephrine
Atropine
Furosemide
An emetic e.g. apomorphine or xylazine
An anticonvulsant e.g. diazepam
A narcotic analgesic ex. Hydromorphone and antagonist - naloxone

Question 3

What is often in a large animal emergency drug kit

Answer 3

Epinephrine
Atropine
Calcium and magnesium parenteral solutions
An antihistamine
An alpha-2 agonist e.g. xylazine
A local anaesthetic e.g. bupivacaine
An analgesic – can be narcotic (butorphanol) or non-narcotic (flunixin)
A narcotic antagonist must be available if narcotics are used

Question 4

What are the minimum requirements for a emergency drug kit

Answer 4

Log your use of narcotics
These are minimum requirements. Most clinics include many more
Antiarrhythmic - lidocaine neat
Bronchodilator - aminophylline
Steroid - dexamethasone
Needles, syringes, catheters
ET tubes
Supplemental O2 (anaesthetic machine, ambu bag)
Chart of precalculated drug doses

Question 5

What should the SOP of a drug kit include

Answer 5

Ensure everyone knows where it is
Restock after every use
Check contents against an inventory list at least monthly
Watch expiry dates
Assign someone the task

Question 6

What are the biggest reasons we reach for the emergency drug kit

Answer 6

Cardiac arrest
Cardiac arrhythmias
Resp arrest
Anaphylaxis
Seizures
Fluid where there shouldn’t be
Brain - cerebral edema→ increased intracranial pressure
Lungs - pleural effusion, pulmonary edema → poor oxygenation
Severe asthma/COPD
Toxin ingestion

Question 7

What routes are you generally going to use to give emergency drugs

Answer 7

IV
- This is by far the best route as the onset of action will be fastest (no absorption period)
Intratracheal
Intrarectal
Transmucosal

Question 8

What are common drugs for cardiac abnormalities

Answer 8

Atropine
Lidocaine
Epinephrine

Question 9

When to use atropine and how does it work

Answer 9

Anticholinergic drug
Binds to and blocks ACh receptors → blocks PNS response
Net result is an overall increase sympathetic tone

Question 10

What are the physiological effects of atropine

Answer 10

Increased HR
Blocks peripheral vasodilation (skin and GI) which results in slight increased BP and moves blood to support heart, lungs, kidney and brain
Bronchodilation
Mydriasis, decrease secretions

Question 11

When is atropine used as an emergency drug

Answer 11

CPR drug
Treating organophosphate toxicity

Question 12

How to use atropine as a CPR drug

Answer 12

To treat bradycardia/cardiac arrest
Give IV

Question 13

How to use atropine
to Treating organophosphate toxicity

Answer 13

Organophosphate inhibits acetylcholinesterase leading to increased circulating ACh
Atropine blocks acetylcholine from binding the cholinergic receptors (both muscarinic and nicotinic); therefore, blocks the parasympathetic signs and blocks the muscle rigidity/paralysis seen with the overstimulation of the nicotinic receptors

Question 14

Mechanism of action for lidocaine

Answer 14

Antiarrhythmic
Mechanism of action: sodium channel blocker
Bind to and decrease the flow of Na+ ions into the cardiac cells
Slows down the rate of depolarization
Extends the refractory period
Result = decreased HR
Also, by slowing the spontaneous depolarization that is occurring abnormally in the heart in the case of arrhythmias, the SA node is able to regain control of the HR and rhythm

Question 15

How do you use lidocaine as an emergency drug

Answer 15

Antiarrhythmic when given systemically (IV)
Used to treat ventricular arrhythmias, including PVCS and ventricular fibrillation (V-FIB)
Systemic overdose can cause anything from sedation/ataxia (slight overdose), seizures and collapse (moderate overdose) to sinus arrest and death
Must only use lidocaine neat
Other form (lidocaine + epi) is only used as a local anaesthetic agent

Question 16

Epinephrine works how

Answer 16

Non selective adrenergic agonists (epinephrine, ephedrine, dobutamine)
Binds and activates alpha 1, beta1, beta 2 adrenergic receptors
Dobutamine is most frequently used in cases of acute heart failure
Epinephrine has slight increased beta-1 activity compared to its activity on other adrenergic receptors

Question 17

What is the main effect of epinephrine

Answer 17

Main effect: increased HR
Also: causes peripheral vasoconstriction (leading to increased BP), increases airway diameter, pupil dilation

Question 18

How do you use epinephrine as a CPR drug and when

Answer 18

Cardiac resuscitation (in cases of cardiac arrest)
High dose (0.1mg/kg)
IV, intratracheal every 2-5 min

Question 19

How do you use epinephrine for emergency drug use

Answer 19

Treatment of anaphylactic shock (allergic reaction)
Low does (0.01mg/kg)
IV, SQ, or IM depending on how emergency and what symptoms of anaphylaxis are
Too rapid IV administration can cause arrhythmias

Question 20

What are some drugs for resp abnormalities

Answer 20

Doxapram
Salbutamol (ventolin ®)

Question 21

How does doxapram work

Answer 21

Resp stimulant
Mechanism of action: centrally acting (works on the brain) to stimulate an increase in resp rate and tidal volume

Question 22

What are the side effects of doxapram

Answer 22

Side effects: due to non specific brain stimulation
Aggression, tremors, seizures, also increased BP, arrhythmia

Question 23

How and when to use doxapram in an emergency

Answer 23

Used in CPR and resuscitating puppies post c-section
Stimulates breathing if apnea (stopped) or bradypnea (very slow)
Reveress resp depression caused by CNS depressants (e.g., premeds and anesthetics)
Can use with opioid-induced resp depression if antagonists not available
1- turn down anaesthetic; 2- manual ventilation; 3- reverse; 4- doxapram
Remember: doxapram is 2nd choice to true reversal
Naloxone if opioid premed
Yohimbine, antisedan if alpha 2 premed

Question 24

Salbutamol (ventolin ®) is used when and how does it work

Answer 24

Beta 2 adrenergic agonist
Mechanism of action: turn on sympathetic bronchodilation by binding to and activating the beta 2 receptors
These drugs also stabilise mast cells so there is less histamine release

Question 25

Side effects of Salbutamol (ventolin ®)

Answer 25

stimulation of B1-receptors in the heart (this is s/e is lessened with local administration)

Question 26

How and when to use salbutamol in an emergency

Answer 26

Used to treat asthma, COPD
Bronchoconstriction is caused by blocking of B2-adrenergic receptors in airways
Injectable available often given with an MDI dispenser (puffer) in animals
Local administration decreased dose and systemic side effects
Aside: theophylline is another drug that can be used for bronchodilation (it is a methylxanthine). Is given systemically and therefore comes with more severe side effects

Question 27

How does diazepam work

Answer 27

Benzodiazepine class tranquilizer
Mechanism of action: increasing GABA (inhibitory neurotransmitter) in the brain. If we increase an inhibitory neurotransmitter, net result is inhibition in the brain
Store in dark; never in plastic; never mix with other drugs
Controlled drug

Question 28

Common side effects of diazepam

Answer 28

Sedation; ataxia; may activate aggression, risk of liver failure in cats

Question 29

When to use diazepam in an emergency

Answer 29

Emergency at home drug
“To be used in the event of a seizure,…very severe, lasting more than 5 min, in the event of more than 1 seizure within a 24h period”
Owners administer by intrarectal route
Emergency in clinic
CRI repeated IV bolus

Question 30

When to use furosemide

Answer 30

Most commonly used diuretic in all vet species
Fastest and strongest acting of all diuretics that act on kidneys

Question 31

How does furosemide work

Answer 31

Causes water loss via teh kidneys
Acts at the loop of henle
Inhibits Na+ reabsorption at the loop
Na+ is lost into urine
Water follows Na+
Later, at the convoluted tubule, Na+ is exchange for K+ (Na+ is reabsorbed; K+ is excreted; water stays in tubule)
Ultimately, causes loss of K+ and water into urine

Question 32

How and when to use furosemide in an emergency

Answer 32

Used to treat cerebral edema, pulmonary edema, pleural effusion, CHF, hypertension, drug toxicity (speeds up elimination)
Used IV emergency situations
Onset of action 5-15 min

Question 33

Mannitol/glycerin is used when and how does it work

Answer 33

Osmotic diuretics
Large sugars that stay in the vessels and draw water out of the interstitial spaces → then are readily secreted into urine (but are not reabsorbed) → increases the osmotic pressure in the urine which also results in more water being retained in the urine

Question 34

How and when do you use mannitol/glycerin in an emergency

Answer 34

Used to decrease intracranial pressure due to cerebral edema
Used to decrease intraocular pressure in acute glaucoma
In hospital emergency IV only

Question 35

Diphenhydramine is used as

Answer 35

Antihistamine
When histamine released, remember we get activation of the inflammation cascade
See acute inflammation
See vasodilation and edema
See bronchoconstriction

Question 36

How and when to use diphenhydramine

Answer 36

Mechanism of actions: binds to histamine receptors and blocks them (stops histamine from binding)
More effective as a prevention than a treatment
Can’t kick histamine that is already bound to the receptor off
As histamine binds and unbinds, it will eventually bind the receptors, but is more effective as a prevention

Question 37

Side effects of diphenhydramine

Answer 37

mild sedation most common, mild anticholinergic effect

Question 38

When to use diphenhydramine in an emergency

Answer 38

Used to treat/prevent anaphylaxis
- Vaccine reaction are the most common indication
Used to treat asthma attacks
- Causes bronchodilation by preventing smooth muscle contraction in the bronchioles
**note: steroids and/or epinephrine would be used in cases of more severe anaphylaxis

Question 39

Naloxone is used when and mechanism of action

Answer 39

Reversal for opioids
Mechanism of action: binds to and blocks opioid receptors
Used to treat opioid induced hyperthermia in cats
Also used to treat resp depression caused by opiods

Question 40

How do fast acting steroids work and when to use

Answer 40

Steroids are potent anti-inflammatory drugs
As allergy/anaphylaxis activating the inflammation cascade, steroids can be very helpful in these cases
Steroids can also be useful in any other condition that involves inflammation - asthma, COPD, etc.

Question 41

Fast acting insulin is

Answer 41

Ultra fast acting or fast acting insulin
E.g. Humulin R
Needs to be refrigerated, so not technically in the emergency drug kit, but good to have in clinic
Used to treat acute diabetic ketoacidosis

Question 42

Apomorphine as an emetic drug for toxins

Answer 42

1st choice in dogs (not used in cats)
Tablet form
Can dissolve in sterile saline and squirt into conjunctiva (some people will also put the whole tablet into the conjunctival sac)
Flush eye after irritating
Or dissolved in saline and filtered via microfilter (to sterilize) and then give IV