ORAL MAXILLOFACIAL AND RECONSTRUCTIVE

SURGERY

BAPUJI DENTAL COLLEGE AND HOSPITAL

SEMINAR

ON

EMERGENCY DRUGS

Moderator:

Dr. Dayananda

Presenter:

Dr. Neeraja Singhla

1

CONTENTS

1. INTRODUCTION

2. EMERGENCY DRUG KIT

3. EMERGENCY DRUG MODULES OR LEVELS

4. EMERGENCY DRUGS IN

- Cardiovascular system

- Respiratory system

- Central Nervous system

- Endocrine system

- Allergic reactions.

5. OTHER EMERGENCY DRUGS USED IN DIFFERENT

EMERGENCIES

6. CONCLUSION

7. REFERENCES.

2

INTRODUCTIONAn emergency is a serious situation that arises suddenly and threatens

the life or welfare of a person or a group of people, as a natural disaster or a

medical crises.

Emergency department is a section of an institution that is staffed and

equipped to provide rapid and varied emergency care, especially for those

stricken with sudden and acute illness or those who are the victims of severe

trauma.

In spite of the most meticulous protocols designed to prevent the

development of life- threatening situations, emergencies still occur.

Prevention, as successful it may be, is not always enough. The entire office

staff must be prepared fully to assist in the recognition and management of

any potential emergency situation.

The management of an emergency begins with the application of the

steps of basic life support: P (positioning), A (airway), B (breathing), C

(circulation) and D (definitive treatment), including the administration of

drugs and hence emergency drugs and equipment must be available in every

dental office.

3

EMERGENCY KITSA number of emergency kits are available commercially for the in the

dental and medical offices. The best emergency drug kit is one the doctor

designs personally to meet his special requirements and capabilities. The

emergency kit should not be complicated. It should be as simple as possible

organized collection of drugs and equipment that is highly effective in the

management of life- threatening situations.

Pallach’s statement that “complexity in a time of adversity breeds

chaos” is all true.

The doctor should remember three things in preparing and using

emergency drug kits:

i) Primary management of all emergencies involves BLS

ii) Drug administration is not necessary for the immediate

management of medical emergencies except in certain conditions

such as anaphylaxis

iii) When in doubt, never medicate.

All the drugs come with drug package inserts. Doctors should save this

information sheet from each drug included in their kit, read it, and take a

note of important information about the drug, including its indications, usual

doses (pediatric, adult and geriatric), adverse reactions, and expiry dates.

4

EMERGENCY DRUGSThe emergency drugs and equipment are now described according to

four levels or modules.

Module one: basic emergency kit (critical drugs and equipment)

Module two: non critical drugs and equipment

Module three: ACLS

Module four: antidotal drugs

Two categories of drugs are described for each module as well as

emergency equipment:

1) Injectable drugs

2) Non-injectable drugs

Most Injectable drugs are prepared in a 1-ml glass ampule or vial. The

number of mgs of drug present in 1 ml of solution varies from drug to drug.

E.g. diazepam is 5mg/ ml, whereas diphenhydramine is 50 mg/ ml and

ephedrine is 10 mg/ ml. the one ml form of the drug is known as its

therapeutic dose or unit dose. However, epinephrine is a major exception to

this basic rule of doses. Although the 1- ml form of 1: 1000 epinephrine is

considered the adult therapeutic dose, a smaller dose- 0.3 ml- is

recommended, with subsequent doses based on patient’s response.

Noninjectable drugs usually are prepared so that one tablet or spray is

the adult therapeutic dose. Many of them are also prepared in pediatric

forms to simplify administration.

Other items of emergency equipment should be available in both

pediatric and adult forms. E.g. face masks, airways etc.

5

ADMINISTRATION OF INJECTABLE DRUGS:

For a drug to exert a therapeutic effect a minimum therapeutic blood

level must be achieved in the target organ. Therefore the ideal route for

emergency drug administration is IV; onset of action is approximately 20

sec, and the drug effect the most reliable of all routes of administration.

Emergency drugs may be administered via the IM route into various

sites; most often the anterolateral aspect of the thigh (vastus lateralis), the

mid-deltoid region of the upper arm, and the upper outer quadrant of the

gluteal region. I.m. administered drugs have an onset of action of about 10

min with normal tissue perfusion. This is somewhat slower with decreased

BP (hypotension). Of these three traditional i.m injectional sites, the mid-

deltoid provides the most rapid uptake of most drugs (because of its greater

tissue perfusion) and is therefore the site of choice. The vastus lateralis is a

close second because of its accessibility and anatomic safety.

One additional site provides an even more effective and rapid uptake

than the mid-deltoid region- the tongue. Emergency drugs can be injected

either into the body of the tongue (intralingual injection) or sublingually for

a more rapid uptake and onset of clinical action. The drug may be

administered in the body of the tongue or floor of the mouth, either intra-

orally or extra-orally. Onset of action is approximately 5-10 min in the

presence of effective circulation, but slower in patients with hypotension.

The steps of BLS must continue as needed while the emergency team

awaits the onset of the drugs action.

MODULE ONE: critical emergency drugs and equipment:

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Injectable drugs:

i) Epinephrine

ii) Histamine blockers

Chlorpheneramine

Dipenhydramine

Noninjectable drugs:

i) Oxygen

ii) Vasodialators

Nitroglycerine

Amyl nitrate

iii) Bronchodialator

Albuterol

Metaproterol

iv) Antihypoglycemics

v) Asprin

Emergency equipment:

i) Oxygen delivery system

ii) Suction and suction tips

iii) Tourniquets

iv) Syringes

v) Magill intubation forceps

MODULE TWO: secondary (non critical) emergency drugs and

equipment:

7

Injectable drugs:

i) Anticonvulsants

Midazolam

diazepam

ii) Analgesics

Morphine sulphate

Meperidine

iii) Vasopressors

Methoxamine

Phenylephrine

iv) Antihypoglycemics

Dextrose 5%

Glucagon

v) Corticosteroids

Hydrocortisone sodium succinate

vi) Antihypertensives

Esmolol

propranolol

vii) Anticholinergics

atropine

Noninjectable drugs:

i) Respiratory stimulant

Aromatic ammonia

ii) Antihypertensives

Nifedipine

Nitroglycerine

Emergency equipment:

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i) Scalpel or cricothyrotomy needle

ii) Artificial airways

iii) Laryngoscope and endotracheal tubes

MODULE THREE: ACLS:

ACLS essential drugs:

i) Epinephrine

ii) Oxygen

iii) Lidocaine

iv) Atropine

v) Dopamine

vi) Morphine sulphate

vii) Verapamil

MODULE FOUR: anti dotal drugs:

i) Opioid antagonist

Naloxane

Nalbuphine

ii) Benzodiazepine antagonist

Flumazenil

iii) Antiemergence delirium drug

Physostigmine

iv) Vasodilator / local anesthetic

Procaine

PRIMARY INJECTABLE DRUGS:

DRUG FOR ACUTE ALLERGIC REACTION

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Drug of choice : EPINEPHRINE

Drug class : Natural catecholamine.

- Epinephrine (Adrenalin) is the drug of choice for the management of

the acute allergic reaction (signs and symptoms appearing within 1

hour of drug administration)

- Epinephrine will be of primary value in the management of the

respiratory and cardiovascular manifestations of allergic reactions.

- Desirable properties of this agent include.

Rapid onset of action.

Potent action as a bronchial smooth muscle dilator (beta

properties)

Antihistaminic properties.

Vasopressor properties.

And its action on heat which include.

Increase heart rate (21%)

Increase systolic blood pressure (5%)

Decrease diastolic B.P. (14%)

Increased cardiac output (51%)

Increased coronary blood flow.

Undesirable actions :

Its tendency to predispose the heart to arrythmias and its relatively

short duration of action.

Therapeutic considerations :

- Acute allergic reaction.

- Acute asthmatic attacks.

- Cardiac arrest.

10

Side effects, contraindications precautions :

- Tachyarrhythmias, both supraventicular and ventricular may develop.

- Epinephrine should be used with contain in pregnancy because it

decreases placental blood flow and may induce premature labor.

- An vital signs should be frequently monitored

Availability :

- Epinephrine for parenteral administration will be supplied in 1:1000

concentration: thus each milliliter will contain 1mg of the agent.

- Because of short duration of action of epinephrine, multiple

administrations maybe necessary during the acute phase of it.

- Unit dose (1ml) ampule are preferred over multiple dose vials

because the unit dose form will prevent the rescuer from inadvertently

administering an overdose.

- A little epinephrine may be life-saving but a lot may be lethal.

- It is used to start administration of epinephrine with 0.3 to 0.5 ml of

solution, I.m or Sc.

Suggested for emergency kit :

On preloaded syringe [1ml of 1:1000 (1mg epinephrine)] and three to

four ampules of 1:1000 epinephrine.

Action: -adrenergic agonist with some - effects.

PHARMACOLOGY

Epinephrine is an endogenous catecholamine

Epinephrine is a direct-acting sympathomimetic agent that exerts its effects

on both and -adrenoceptors.

Clinical pharmacology:

11

- Parenteral administration of epinephrine produces hemodynamic

metabolic and electrocardiographic effects.

- Rapid intravenous injection produces rapid rises in systolic and

diastolic blood pressure.

- Slow IV or subcutaneous injection, however produces a moderate

increase in systolic BP and drop in diastolic BP caused by a

predominantly B2 stimulant vasodilator effect or blood vessels in

skeletal muscle.

- In infusion produces hypokalemia.

Pharmacokinetics

- Pharmacologically active concentrations of epinephrine are not

achieved following oral administration as it is rapidly oxidized and

conjugated in the gastrointestinal mucosa and liver.

- Absorption from subcutaneous tissue is slow because of local

vasoconstriction : effects are produced within 5 min.

- Absorption is more rapid after I.m than after subcutaneous injection.

- Epinephrine is rapidly metabolized in the liver, neuronal tissues and

else where.

- Upto 91% of IV dose is excreted in urine.

Metabolism :

Rapidly metabolized by oxidation de-amination and O-methylation,

catalyzed by enzymes monoamine oxidase and catechol-O-methyl

transferase respectively.

Therapeutic use :

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1) TT of acute allergic reactions.

2) Emergency ft of life-threatening angioedema and anaphylactic shock.

3) Adjunctive use in management of cardiac arrest

4) Open-angle glaucoma.

Mode of use :

- Route of administration and dose vary with the indication and the

severity of condition.

- Repeated doses may be given in life threatening situations but dosing

more frequently than every 5 min is associated with higher incidence

of side effects and caution is susceptible patients.

Indications :

1) Acute allergic reactions :

Acute allergic reactions with airways obstruction should be treated

with 200 to 5mg epinephrine by SC or IM injection.

- This may repeated at internals of 15 to 30 min. depending on

response.

- SC should be preferred

2) Life threatening angioedema and anaphylactic shock :

- 1st line of treatment in these medical emergencies, mode of action of

epinephrine is not entirely clear but it is likely that its -agonist

action reverses vasodilation and edema and B2 receptor stimulation

relates bronchial smooth muscle in bronchoconstriction.

- A dose of 500 g to 10mg (0.5-1ml of epinephrine 1 in 1000

injection) should be IM as soon as possible and repeated every 10 min

until improvement occur.

3) Cardiac Arrest :

13

- Epinephrine is one of a number of tt 1 used in management of cardiac

arrest. Myocardial and cerebral blood flow is substantially increased

by epinephrine during CPR owing to prevention of arterial collapse

and augmentation of coronary and cerebral perfusion pressures.

- 1mg (10ml of a 1 in 1000) injection of epinephrine should be given

by peripheral or central IV route.

- Endotracheal administration is venous access is difficult

- Intracardiac administration should be regarded as last resort as it

carries the risk of coronary artery laceration, cardiac tamponade, and

pnuemothorax, in addition.

Intra cardiac injections cause interruption of external chest compression

and ventilation.

4) Open-angle glaucoma :

Epinephrine 0.5% and 1% eye drops are used to reduce intraocular

pressure in open-angle glaucomas may act by decreasing the rate of aqueous

humor production, enhancing aqueous outflow or by both mechanisms.

Contraindications :

1) Hyperthyroidism : patients with hyperthyroidism are hypersensitive

to the effects of epinephrine. Toxic effects may be produced with low

doses of epinephrine and therefore great caution must be exercised.

2) Hypertension : The pressor effects or epinephrine are exaggerated in

hypertensive patients and great care must be taken to avoid severe

hypertension.

3) Ischemic heart disease : Angina and further myocardial ischemia

may be precipitated by epinephrine in patients with underlying

ischemic heart disease. Ventricular fibrillation is particularly likely to

be induced in such patients.

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4) Diabetes : Epinephrine should be used with case in diabetic patient as

hyperglycemia, caused by -receptor mediated suppression of insulin

release will occur.

5) Angle-closure glaucoma : Papillary dilation caused by epinephrine

may worsen angle closure glaucoma and epinephrine is

contraindicated in this condition.

Adverse reactions :

Acute over dosage :

Over dosage may cause cardiac arrythmias, cerebral hemorrhage and

pulmonary edema.

Severe or irreversible adverse effects

Local ischemic necrosis may be produced if epinephrine is used in

excess in combination with L.A.

Symptomatic adverse effects :

Adverse effects such as anxiety, dyspnea, restlessness, palpitations,

tachycardia, tremors, weakness, dizziness, headache and coldness of

extremities may occur with even small doses of epinephrine.

Children

The use of epinephrine in children requires that the body weight of

the patient be known, or atleast carefully estimated.

The dose recommended in cardio pulmonary resuscitation is 10 mg.kg -1

(0.1ml. Kg-1 of 1 in 1000 ml)

Cardiovascular effects :

The cardiovascular effects of epinephrine results from epinephrine

induced stimulation of and - adrenergic receptors.

Small doses of epinephrine (1 to 2 mg/min IV) administered to adults

stimulate principally beta2 receptors in peripheral vasculature.

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Stimulation of beta1 receptors occurs at somewhat larger doses

(4mg/min IV) where as large doses of epinephrine (10 to 20 mg/min IV)

stimulate both and -adrenergic receptors with the effects of stimulation

predominantly in most vascular beds,

- Epinephrine stimulates 1 receptors to cause an increase in systolic

BP, heart rate, and cardiac output. There is modest decrease in

diastolic BP, reflecting vasodilation in skeletal muscle vasculature

due to stimulation of B2 receptors.

- The net effect of these systemic blood pressure changes is an increase

in pulse pressure and minimal changes in mean arterial pressure.

- Epinephrine predominantly stimulates alpha, receptors in the skin,

mucosa, and hepatocellular vasculature producing increasing

vasoconstriction.

- In skeletal muscle vasculature epinephrine principally stimulation 2

receptors producing vasodilation.

- The net effect of these peripheral vasculature changes is preferential

distribution of cardiac output to skeletal muscles and decreased

systemic vascular resistance.

Airway smooth muscle :

Smooth muscle of the bronchi are related by virtue of epinephrine

induced activation of 2-adunnjic blockade, reflecting epinephrine-induced

stimulation of -receptors. 2- Stimulation, by increasing intracellular

concentration of camp decreases release of vasoactive mediators associated

with symptoms of bronchial asthma.

Coagulation :

16

Blood coagulation is accelerated by epinephrine, presumably due to

increased activity of factor V. A hypercoagulable state present during the

intraoperative and post operative period may reflect stress associated release

of epinephrine. Epinephrine increases the total leukocyte count but at the

same time causes eosinopenia.

ANTIHISTAMINE :

Drug of choice : CHLORPHENIRAMINE (CHLOR-TRI-METON)

Alternative drug : DIPHENHYDRAMINE HCL (Benadryl)

- Antihistamines will be of value in the treatment of the delayed

allergic response (onset of symptoms more than 1 hour after

administration of allergen) and in the definitive management of the

acute allergic reaction (administered after epinephrine has terminated

the acute life-threatening phase of the reaction.

- Antihistamines are competitive antagonists of histamine. They do not

prevent the release of histamine from cells in response to injury,

drugs or antigens but do prevent access of histamine to its receptor

site in the cell and there by block the response of the effector cell to

histamine.

- Antihistamines are more potent in preventing the actions of histamine

than in reversing these actions once they develop.

- An interesting action of many antihistamines is that they are also

potent local anesthetics, E.g. diphenhydramine and tripelennamine.

- The choice of an antihistamine for the emergency kit was made after

considering that most dental patients are ambulatory and may leave

the dental office unescorted.

Therapeutic indications :

- Delayed allergy,

17

- Definitive management of acute allergy

- For local anesthesia.

- When history of alleged allergy is present.

Side effects, contraindications and precautions :

- Side effects include CNS depression,

b) Decreases BP

c) Thickening of bronchial secretions resulting from drugi

drying action

- Contraindicated in treatment of acute asthamatic episodes.

Availability :

Chlorpheniramine, 10 mg / ml (1ml ampule)

Diphenhydramine, 10 mg / ml (10 and 30 ml multidose vial)

Suggested for emergency kit :

Chlorpheniramine, 10mg / ml (3 to 4 ampules)

Diphenhydramine, 50 mg/ ml (3 to 4 ampules)

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CHLORPHENIRAMINE (MALEATE)

Belongs to the alkylamine group of classic H1 Histamines.

Pharmacology :

It clinically most relevant effect is on the smooth muscle of the

vascular the where it blocks histamine-induced increased capillary

permeability, and incompletely prevents the histamine-induced fall in the

blood pressure.

Clinical pharmacology :

Like other H1 antihistamines, chlorpheniramine antagonizes various

physiological and pathophysiological effects of histamine including

increased capillary permeability and dilatation the formation of edema, the

‘flare’ and ‘itch’ response, and the constriction of gastrointestinal and

respiratory smooth muscle.

Acute overdose :

When taken in excessive doses the intoxicated patient is unconscious

and shows hypertension, coma, and occasionally, convulsions which are

difficult to it.

DIPHENHYDRAMINE

- is a H1 histamine receptor antagonist.

Clinical pharmacology :

- Histamine is found in high concentrations in most cells in skin, lung

and intestinal mucosa.

- Its actions at H1 sites include contraction of bronchial intestinal and

vascular smooth muscle, but relaxation of smooth muscle in blood

vessels.

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- Histamine is responsible for triple response of flore, swelling and

vasodilation which follows tissue injury.

Use :

Premeditation, emesis, motion sickness.

ANTICONVULSANT :

Drug of choice : Diazepam- benzodiazepine

Alternative drug: Barbiturates (thiopentone)

Seizures disorders may occur in dental office in several circumstances :-

Over dose reactions of L.S.

Epileptic seizures.

Febrile convulsions.

Diazepam is the preferred drug because seizure disorders are characterized

by stimulation of CNS and cardio respiratory systems followed by a period

of depression of these same systems.

- Diazepam will usually terminate seizure activity without pronounced

depression of the respiratory and cardiovascular systems.

- When barbiturates are administered to terminate seizure activity, the

degree of depression is accentuated and its duration prolonged

because of pharmacologic actions of barbiturate leading to respiratory

arrest and a profound cardiovascular depression or collapse.

Therapeutic indications :

- Termination of prolonged seizures

- Local anesthetic seizures

- Hyperventilation syndrome

- Thyroid stone.

20

Side effects :

Major side effect of diazepam is respiratory depression or arrest,

however careful titration during administration this is unlikely to occur.

Availability :

Diazepam (valium) 5mg/ml (2ml preloaded syringe)

5mg / ml (2m, 10ml vial)

Suggested for emergency kit :

One 10 ml vial of diazepam, 5mg / ml

- IV injections of diazepam should always be administered slowly

(about 5-1 ml/min) because unduly rapid injection may induce apnea.

- Intra-arterial and extravasation must be avoided.

- The absorption of diazepam administered rectally in the form of a

rectal solution is rapid, peak plasma diazepam levels occurring within

10 min.

- IM injection may cause local pain and erythema : IM administration

of diazepam (but not IV administration) can lead to rise in creatinine

phosphokinase activity as a result of muscle damage.

- Where a very rapid onset of effect is needed but parenteral

administration is inadvisable, a rectal solution can be used.

E.g. : for emergency control of febrile convulsions.

Indications For IV Administration :

Diazepam is indicated IV when a rapid response is desired and may

be useful in acute anxiety or tension states related to stressful conditions, to

control prolonged seizure activity (status epilepticus) including severe

recurrent seizures: for the relief of muscle spasm in cerebral palsy, athetosis,

the rare stiff mass syndrome and adjunctively in tetanus.

21

The absorption of diazepam given. IM is slow and unreliable. Oral

administration is preferable when IV route is unnecessary.

Indications :

Status epilepticus :

The dose is 0.15 – 0.25 mg/ kg body weight .IV repeated if necessary

after 10-15 min, or continuous drip infusion but not more than 3mg. kg body

weight in 24 hours.

TETANUS :

0.1-0.3 mg. kg body weight IV at intervals of 1-4hours.

EXCITATION STATES :

0.1-0.2 mg.kg-1 body weight IV and repeated 8 hours interval.

NARCOTIC ANTAGONIST :

Drug of choice : Naloxone (Narcan)

Alternative drug : nalbuphine (Nubain)

- If a narcotic analgesic or pentazoline is used for psychosedation

techniques, a narcotic antagonist must be readily available.

- Narcotic antagonist are indicated for reversal of narcotic depression,

including respiratory depression.

Side effects : Contraindications : precautions

The duration of naloxone is short – quite possibly shorter than that of

the narcotic it is reversing. This situation may lead to recurrence of

respiratory depression following a period of apparent recovery.

For this reason all patients receiving naloxone must be observed for at

least 1 hour after its administration.

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Availability : Naloxone (Narlam), 0.4 mg/ml (1m ampule)

Emergency kit : Naloxone (Narlam), 0.4 mg/ml (1m ampule)

Mode Of Use

- Naloxone can be administered by IV, IM or SC in opioid over dose,

5-10 mg. kg is the used initial IV dose and may be repeated at 2-3

min intervals until the desired response is seen.

- At least 2mg should be used to constitute an adequate trial in

overdose of unknown cause.

- The duration of action of long acting opioids may outlast that of an

IV dose of naloxone so patient should be carefully monitored for

signs of returning opioid depression.

- Iv infusions have been employed to avoid this problem commencing

at 2-5 mg. kg hourly and adjusted act to response.

- Absorption is good from IM and SC sites but rate of onset is slower

than via the IV route.

Action:

Competitive antagonist at opioid receptors.

Antagonizes endogenous or exogenous opioids, reverses all effects such as

analgesia, respiratory depression, papillary constriction, coma and

convulsion.

NALOXONE (HYDROCHLORIDE)

Naloxone is the 1st opioid antagonist to be developed that is devoid of

agonist activity.

Indications :

1) Reversal of effects of opioid drugs.

2) Diagnosis and treatment of opioid addiction.

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3) Prevention of intravenous abuse of opoiod tablets.

1) Reversal Of Effects Of Opioid Drugs

The treatment of the life threatening consequences of known or

suspected opioid overdose is the prime indication for naloxone.

In case of over dose following therapeutic use of opioids E.g.

postoperatively, a small initial dose is used in an attempt to reverse a

respiratory depression without loss of the opioid analgesia. In such cases

0.1mg doses may be administered at 2-3 min intervals until the required

effect is achieved.

2) Diagnosis and treatment of opoid addiction:

The precipitation of a withdrawal reaction by naloxone has been used

as a diagnostic test in cases of suspected opioid dependence, though care

must be taken to avoid a severe withdrawal reaction.

Adverse reactions :

Extreme hypertension may follow naloxone administration both in

opioid addicts and after large therapeutic doses of opioid for pain relief.

SECONDARY INJECTABLE DRUGS :

Secondary injectable drugs are agents that are deemed important but

not absolutely essential to the successful management of emergency

situation.

ANALGESIC DRUGS :

Drugs of choice : Morphine sulfate – opioid agonist.

Alternative drug : Meperidine (Demerol)

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Actions : Narcotic analgesic.

- Analgesic medications will be useful during emergency situations in

which acute pain or anxiety is present. In most instances, the presence

of pain or anxiety will cause an increase in the workload of the heart

that may prove detrimental to the well being of patient. To such

circumstances are acute myocardial injection and congestive heart

failure. The choice of drugs include the narcotic agonists morphine

sulfate and meperidine (Demerol)

Therapeutic indications :

- Intense, prolonged pain and / or anxiety.

- Acute myocardial infarction

- Congestive heart failure.

Side effects : precautions : contra indications :

- Potent CNS and respiratory depressants.

- Vigilant-monitoring of vital signs is mandatory

- Use of narcotics is contraindicated in victims of head injury and

multiple trauma.

- Use with car in patients with compromised respiration.

Availability : Morphine sulfate, 10mg/ml (in 1ml ampule)

Meperidine (Demerol), 50mg/ml (in 2ml ampule)

Suggested for emergency kit :

Morphine sulfate, 10 mg/ml (2 or 3 1 ml ampules) or

Meperidine 50 mg / ml (2 or 3 1ml ampules).

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VASOPRESSORS :

Drugs of choice – methoxamine ( vasoxyl)

Alternative drug – phenylephrine (Neo-symphrine)

- Vasopressors such as methoxamine (vasoxyl) and phenylephrine

(neo-synephrine) are drugs that produce moderate blood pressure

elevations through the mechanism of peripheral vasoconstrictions.

- Methoxamine is a clinically useful Vasopressor with, sustained action

and with little effect on the myocardium or CNS.

- Its vasopressor action is associated with marked increase in the

peripheral resistance and no increase in cardiac output. A

compensatory bradycardia accompanies the rise in BP.

- Onset of the vasopressor action is almost immediate following IV

administration and may persist for upto 60 min.

Therapeutic indications :

- Management of hypotension, in which the state of the heart is

unknown and the intent is to raise the blood pressure without cardiac

stimulation.

- Possible uses are in syncopal reactions, drug over dose reaction, post

seizure states, acute adrenal insufficiency, allergy.

Side effects, contraindications, precautions :

- Parenteral administration of most vasopressor is contraindicated in

patient with high BP or ventricular tachycardia.

- Extreme caution in patient with hyperthyroidism, Bradycardia, partial

heart block, Myocardial disease or severe arthrosclerosis.

26

Availability :

- Methoxamine (vasoxyl), 10mg/ml, and 20mg/ml

91ml ampules and 10ml vials)

- Phenylephrine 10mg/ml (1ml ampule)

Suggested for emergency kit :

- Methoxamine 10mg/ml (2 or 3 1ml ampules)

- Phenylephrine 10mg / ml (2 or 3 ml ampules)

METHOXAMINE :

Methoxamine is a pure a1- adrenoceptor agonist used to treat

hypotension resulting form vasodilation.

Pharmacology :

It is a constrictor of vascular smooth muscle through its action upon

post synaptic -receptors.

Clinical pharmacology :

Methoxamine produces its effects by a direct -adrenoreceptor

stimulant action on both resistance and capacitance vessels. There is

resultant dose-related increase in systemic vascular resistance and arterial

blood pressure.

Bradycardia occurs as a result of increased vagal activity as a reflex

response to the vasopressor effects of methoxamine – Bradycardia can be

abolished by atropine.

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Contraindications :

1) Hyperthyroidism: High doses of methoxamine cause marked

increases in BP associated with severe bradycardia.

2) Severe hypertension : High doses of methoxamine cause marked

increases in BP associated with severe bradycardia.

3) Myocardial disease : The increase in systemic vascular resistance

cause by methoxamine results in increased cardiac work and O2

demand.

CORTICOSTEROIDS :

Drug of choice : hydrocortisone sodium succinate

Alternative drug : Methyl prednisolone sodium succinate.

- The primary value of the corticosteroids is in the prevention of

recurrent episodes of anaphylaxis.

- Corticosteroids are also important in the management of acute adrenal

insufficiency.

- Studies showed that maximal effectiveness may not occur for upto 60

min after IV administration.

- It appears likely that the anti-allergic effects of the corticosteroids are

simply a manifestation of the nonspecific anti-inflammatory action of

the adrenal glucocorticoids.

Therapeutic indications :

- Definitive management of acute allergy

- Acute adrenal insufficiency.

28

Side effects, contraindications and precautions :

When administered for an emergency treatment there are many

factors to be considered, such as presence of pre-existing injection, peptic-

ulcer, and hyperglycemia.

Availability :

Hydrocortisone sodium succinate, 50mg/ml (2ml vial)

Methyl prednisolone sodium succinate 50mg/ml (1ml vial)

Action : suppression of anti-inflammatory response rather than to inhibition

of production of immunoglobulin.

HYDROCURTISONE :

Hydrocortisone is a naturally occurring corticosteroid used

principally for its anti-inflammatory and immunosuppressive actions, or as

hormone replacement therapy.

Pharmacology

Hydrocortisone is the principal gluco-corticosteroid synthesized by

the adrenal cortex in man. It influences carbohydrate, protein and lipid

metabolism. The anti-inflammatory and immunosuppressive effects of

hydrocortisone are its main therapeutic actions. Hydrocortisone inhibits the

inflammatory response whatever the inciting agent, and is thought to be

mediated by reduction in the formation of various vasoactive chemicals

released during inflammation such as kinins histamines, lysosomal

enzymes, and the complement system.

29

INDICATIONS :

1) Replacement therapy for adrenocortical failure or hypopituitarism.

2) Status asthamaticus.

3) Anaphylactic reaction.

4) Soft tissue or joint inflammation.

5) Congenital adrenal hyperplasia.

6) Apthous ulcer.

1) Replacement therapy for adrenocortical failure or hypopituitarism.

Acute adrenal failure is a medical emergency, and may follow abrupt

cessation of corticosteroid therapy. in chronic primary adrenal failure,

hydrocortisone is usually administered usually at a dose of 20-30 mg daily.

A common dose schedule is long hydrocortisone in morning and 10mg late

afternoon.

Apart from adequate IV saline and glucose fluid replacement IV

hydrocortisone as sodium succinate or phosphate derivative should be given

at a dose of 100 mg 8 hourly adrenal failure secondary to hypopituitarism is

treated as a chronic adrenal failure. Therapy is generally guided by the sense

of well being, alertness, postural changes in BP, weight and strength.

2) Status asthamaticus :

IV hydrocortisone succinate in doses of 100-200 mg every 6 hour is

usually administered.

3) Allergic and anaphylactic reactions :

Allergic and anaphylactic reactions manifest in a variety of ways

including has sever, urticaria, angioneurotic edema, and shock. Life

threatening reactions should be treated with large doses (100-500 mg every

6 hours) of IV hydrocortisone succinate. The effects of hydrocortisone takes

30

some hours to develop, and other therapy such as IM or SC epinephrine

(0.3-1mg) should be considered.

ANTIHYPOGLYCEMICS :

Drug of choice – 5% dextrose sol.

Alternative drug – glucagon.

- In management of hypoglycemic patient the mode of therapy will

depend in large part on the patient’s level of consciousness.

- Oral carbohydrate is much the preferred mode of therapy; however is

a patient is unconscious or severely obtunded, the oral route must not

be employed;

- At this situation 50 ml of a 50% dextrose solution may be

administered IV. When IV route not available, glucagons may be

administered.

- Glucagon is normally produced in pancreas and acts to rapidly elevate

the blood glucose level by mobilizing hepatic glycogen and

converting it to glucose; thus glucagon will be effective only if

hepatic glycogen is available.

- Not be effective in starvation or chronic hypoglycemic states.

- Oral carbohydrates are administered as soon as the patient begins to

respond.

Therapeutic indications :

- Hypoglycemia

- Diagnostic tool in unconsciousness or seizures of unknown origin.

Side effects : Contraindications and precautions :

- 50% dextrose may produce tissue necrosis should infiltration occur.

31

- Glucagon either IM or IV is contraindicated in starvation states and in

chronic hypoglycemia.

Availability :

Glucagon, 1mg (1 unit) dry powder with 1ml diluent

10mg dry powder with 10 ml diluent,

50% dextrose (50mg bottle)

Suggested for emergency kit :

Glucagon, 1mg/ml (two or three 1ml viols) or

50% dextrose (1 bottle)

DEXTROSE :

Dextrose also called glucose, is a physiological carbohydrate used as an

energy source in parenteral nutrition.

Clinical pharmacology :

Physiological amounts of dextrose given IV have no measurable

acute pharmacodynamic effect although the volume of fluid given with in

may cause circulatory overload in a patient with limited cardiac reserve.

Adverse effects :

- Dextrose administration must be cautions in severe under nutrition.

Sodium retention, edema, and heart failure may be induced.

- Hypophosphatesia occurs is dextrose is administered as feed without

added phosphate. This may result in parasthesia, seizure, coma and

death.

- The hypophosphatemia is presumably the result of phosphorylation of

dextrose as it enters the cell.

32

- Anaphylactoid reactions were reported in 2 patients with asthma and

diabetes mellitus after IV infusion of 50% dextrose solution, probably

as a result of dextrose induced histamine release.

INJECTABLE DRUG FOR ADVANCED CARDIC LIFE

SUPPORT (ACLS)

SODIUM BICARBONATE (NaHCO3) :

- During cardiopulmonary arrest, both metabolic and respiratory

acidosis occur.

- Effective ventilation of the lungs is major factor in management of

the acidosis accompanying cardiac arrest, especially in the removal of

CO2 that has been retained (hypercarbia) by ventilatory failure or

insufficiency.

- NaHCO3 is effective in management of metabolic acidosis.

The HCO3- ion combines with the hydrogen (H+) ion in the blood, there by

elevating the pH of the blood adequate ventilation is necessary wherever

NaHCO3 is administered because CO2 is produced during the reaction.

HCO3- + H+ H2CO3 CO2 + H2O

Therapeutic indications :

Reversal of metabolic acidosis occurring during anaerobic

metabolism in cardiopulmonary arrest.

Side effects :

- Metabolic alkalosis

- Hypernatremia, ad hyperosmolatity

Availability : 1 mEq / ml (50 ml ampule)

33

ATROPINE SULPATE :

Atropine is a parasympatholytic drug that decreases vagal tone

through its vagolytic action, there by increasing the rate of discharge of the

sinoatrial node.

Indications :

Management of severe sinus bradycardia when accompanied by

symptomatic hypotension or hypotension that might impair coronary artery

blood flow.

Side effects : contraindications

Atropine administration is therefore not recommended when bradycardia

is not associated with hemodynamic compromise (hypotension)

Availability : Atropine 5 mg [ 5ml (0.1 mg / ml) reloaded syringe]

Suggested kit : one preloaded syringe

CALCIUM CHLORIDE (CaCl2) :

Indications : Cardiac arrest

Electro mechanical dissociation and

Ventricular asystole

Calcium chlorides is effective in profound cardiovascular collapse in which

an orderly electrical rhythm is associated with an ineffective ejection of

blood from the heart (electromechanical dissociation).

Side effects

- Rapid administration of CaCl2 can produce a severe sinus bradycardia

or sinus arrest is the heart is beating.

34

- Calcium cannot be administered along with sodium bicarbonate

because calcium will precipitate out

SODIUM BICARBONATE :

NaHCO3 is a systemic alkalinizing agent. It increases plasma

bicarbonate, buffers excess hydrogen ion concentration and raises blood pH,

there by reversing the clinical manifestations of acidosis.

Also be used to replenish electrolyte imbalance as a it adjacent for

fevers diarrhea where the loss of bicarbonate can be significant.

Pharmacology Sodium bicarbonate is a felt which on reaction with acid will raise the

pH by lowering the concentration of hydrogen ion.

NaHCO3 + HCl = CO2 + NaCl + H2O

Thus NaHCO3 is used as an antacid in stomach or as an agent to

increase the pH of urine or whole body.

Indications :

1) Management of acidosis in cardiac arrest.

2) Management of metabolic acidosis in

a) fever send disease

b) uncontrolled diabetes

c) circulatory in sufficiency from shock or dehydration

3) Alkalinization of urine.

Contraindications

1) In hypoventilatory states

2) Metabolic and / or respiratory alkalosis.

3) Hypocalcemia

35

4) Chloride depletion

Indications :

1) Cardiac arrest

Cardiac arrest is often associated with a systemic acidosis with both

respiratory and metabolic components. It was believed that this acidosis

exacerbated electrolyte disturbances, antagonized the effects of

catecholamines, and reduced the threshold for ventricular fibrillation. This

provides the rationale for the aggressive use of NaHCO3 during CPR. The

suggested initial dose is 1 m Eq. Kg body wt and further administration is to

be guided by the measurement of arterial / venous blood pH and CO2 levels.

NaHCO3 should never be given to its who are not ventilating

adequately.

2) Metabolic Acidosis

In other acute forms of metabolic acidosis, Na

HCO3 may be added to other IV infusions.

Parenteral solutions containing calcium ions should be avoided as

precipitation may result.

Recommended dose is one half of the calculated requirement

followed by reassessment of the acids base.

Contraindications

1) Hypoventilation : The respiratory acidosis from hypoventilation

should be connected by improving the ventilation of the patient.

Bicarbonate should never be given if the patient is not breathing

normally.

36

2) Chloride depletion : Bicarbonate should not be used in patients losing

chloride owing to vomiting or a continuous gastrointestinal fution .

there is increased risk of severe metabolic alkalosis.

3) Hypocalcemia : There is increased risk that alkalosis may induce

tetany

4) Hyperosmolar states : 8.4% bicarbonate high osmolar value ; so use

of NaHCO3 should be carefully considered in

a) Anuria or oliguria – because of increased risk of sodium

retention.

b) Edematous sodium-retaining conditions such as hepatic

cirrhasis, CHF, impaired renal function, toxemia of pregnancy.

CALCIUM CHLORIDE :

Calcium has long bean known to increase the force of myocardial

contraction. In addition, calcium ions also each enhance ventricular

excitability.

ATROPINE

Atropine, an alkaloid extracted from atropa belladonna.

Clinical pharmacology

Major actions :

Atropine has widespread central and peripheral effects. In the usual

clinical dose of .5 to 1.0 mg its peripheral effects may include tachycardia

without increased contractility, decreased production of sweat, bronchial,

nasal, lacrimal and gastric secretions, and inhibition of micturition.

37

Cardiac Action

Atropine increases sinus rate, and sinoatrial and Av conduction.

Although it is generally believed that the usual therapeutic dose (0.4 –

1 mg, commonly 0.6 mg) causes tachycardia.

Atropine inhibits salivary secretion, producing a dry mouth and

difficulty in talking.

Indications:

I) BRADYARAYTHMIAS AND MYOCARDIAL INFARCTION

Atropine is the it of choice in the severe bradycardia and hypotension

or syncope associated with a hyperactive carotid sinus reflex and vagal over

activity (vaso vagal syndrome).

Atropine is also useful in severe bradycardia or temporary sinus arrest

occurs during cardiac investigation initial dose of 0.6 or 1.2 mg is sufficient.

Atropine may be of value in the it of Av conduction block caused by

excessive vagal tone after acute myocardial infarction; it may reduce the

degree of block.

Atropine should be given only when bradycardia is associated with

signs or symptoms of hypotension and hypoperfusion, conduction

disturbance or entopic arrhythmias.

2) ANESTHETIC PREMEDICATION : Inhibition of secretion. Atropine

is a long standing anesthetic premedication, used to reduce salivary and

tracheobronchial secretions caused by many inhaled anesthetics, especially

diethyl ether. It is less potent antisialogogue to than scopolamine but has

less prolonged action and less postoperative sedation and confusion.

The concomitant bronchodilator action of atropine may be a useful

bonus in anesthetic use.

Conventional dose 300 – 600 mg in adults

38

3) ANESTHETIC PREMEDICATION : INHIBITION OF CARDIAC

REFLEXES

Atropine is the traditional premedication for the prevention of the

reflex bradycardia that may be associated with laryngoscopy, tracheal

intubation and for the prevention of occulo-cardiac reflex during ophthalmic

surgery.

4) Ophthalmic use : Local administration of atropine in form of eye drops

is used in ophthalmology to produce mydriasis and cycloplegia.

CONTRAINDICATION

1) Glaucoma

Both local and systemic use of atropine can precipitate acute

glaucoma, especially in patients predisposed to narrow – angle glaucoma.

2) Chronic lung disease

Because of the reduction of bronchial secretions there may be a

marked increase in viscosity

PRIMARY NON INJECTABLE DRUGS

OXYGEN :

Alternative drug : none

Most important drug in the entire emergency kit

O2 is supplied in variety of cylinder sizes but the minimal acceptable

size is E cylinder. E – cylinder provide O2 – 30 min in emergency.

haye cylinders (H) smaller (A through D)

O2 supplied in canisters through a chemical reaction is not adequate

for the emergency kit.

39

Availability

Compressed gas cylinders in variety of sizes.

VASODILATOR

Drug of choice : Nitro glycerin

Alternative drug : Amyl nitrite

Vasodilators are used in the immediate management of chest pain –

(angina pectoris and acute myocardial infraction)

Two varieties – Nitroglycerin (TNG) as a tablet ad spray and an

inhalant, amyl nitrite.

Nitroglycerin acts in 1 to 2 min. when placed sublingually

Amyl nitrite is available as an inhalant it is supplied in yellow

vapourule, 0 – 3 ml, which when crushed and placed under the

victims nose will act in about 10 sec to produce profound

vasodilation.

Duration of action of amyl nitrite is shorter than that of TNG.

Side Effects : Contraindications And Precautions

Transient pulsating headache,

Facial flushing

Hypotension

Contraindicated in hypotensive patients

Side effects of amyl nitrite are more intense which include flushing of

the face pounding pulse dizziness, intense headache and

hypotension.

Availability:

Nitroglycerin tablets , 0.1, 0.3, 0.6 mg tablet nitroglycerin spray.

Nitrite vapuroles (yellow), 0.3 ml.

40

Emergency kit :

One spray bottle of nitroglycerin (0.4 mg)

NITROGLYCERIN

Indications

1) Relief of angina pectoris

2) Prophylaxis of angina pectoris

3) Management of angina pectoris

4) Management of acute cardiac pulmonary edema

5) Management of chromic heat failure

6) Management of acute myocardial infraction.

7) Management of postoperative hypertension.

Contraindications

1) Obstructive hypertrophic cardiomyopathy

2) Raised intracranial pressure.

3) Cardiac tamponade.

Relating contraindication

1) Glaucoma

2) Mitral value proplapse

Mode of Use

All the clinical use depends upon production of venous and arterial

dilatation and to some extent of dilatation of coronary arteries.

1) Relief of angina pectoris

Sublingual nitroglycerin is widely used for the relief of effort induced

and resting angina. It acts by reducing cardiac work. Effects are more

41

pronounced in the standing than in the supine position and may lead to

syncope if vasodilation is pronounced. It is preferable to take nitroglycerin

in sitting position.

Nitroglycerin sublingually in a dose of 0.3 – 0.4 mg and repeated

every 3 min until either the pain resolves or max of 4 to 5 tablets have been

taken.

2) Prophylaxis of angina pectoris

For prophylaxis of angina pectoris, sublingual nitroglycerin is very

effective but its duration of effect last only for a few min to max of half an

hour. Nitroglycerin ointment every 4 to 6 hr may be prescribed and effects

last for several hours.

Another alternative is buccal nitroglycerin in dose of 3 – 5 mg every

6 hr.

Nitroglycerin patches, although claimed to have 24 hrs efficacies,

have been shown to be ineffective for 24 h prophylaxis of angina pectoris.

3) Unstable angina

Intravenous nitroglycerin is a very effective dry for relief of chest

pain by myocardial ischemia dose of upto 200 mg min or higher have to be

used.

4) Management of CHF :

Nitroglycerin by reducing venous return, lowers elevated end –

diastolic pressure in the right and left ventricles and improves myocardial

function. The cardiac output either does not change or increases.

42

5) Management of hypertension

IV nitroglycerin lower raised arterial presence and effective in

selected group of patient.

Contraindications :

1) Obstructive hypertrophic cardiomyopathy

By causing vasodilatation nitroglycerin reduces venous return to heart

and increases left ventricular out flow obstruction.

2) Raised intracranial pressure

Should be avoided, or venodilatation may further increased already

raised intracranial pressure

3) Cardiac tamponade

Filling of the ventricles is impaired and nitroglycerin may further

reduce this and cause syncope.

4) Glaucoma

This is a relative contraindication of nitroglycerin as intraoculas

pressure may increase.

Acute over dosage

Include hypotension, tachycardia, warm flushed skin, headache,

palpitations and syncope.

SECONDARY NONINJECTABLE DRUGS

Drug of choice : Aromatic ammonia

- Aromatic ammonia is the agent of choice as a respiratory

stimulant for the emergency kit.

43

- Available in a silver – gray vapourule, which is crushed and

placed under the victims nose until respiratory stimulation is

effected.

Aromatic ammonia (a noxious odor) acts by irritating the mucous

membrane of the upper respiratory tract, thereby stimulating the respiratory

and vasomotor centers of the medulla ; this in turn increases respiration and

B.P.

Therapeutic Indications

Respiratory depression not induced by narcotic andgesies

vasodepressor syncope.

Side effects : contra indications ad precautions

Caution with person with chronic obstructive pulmonary disease

(OPD) or asthma because it may precipitate bronchospasm resulting from its

irritating effects on the mucous membranes of the upper – respiratory tract.

Availability : Silver gray vaporole (0.3 ml aromatic ammonia)

Suggested for emergency kit :

12 vaporoles

next to O2, aromatic ammonia is the most commonly used drug in

emergency kit.

ANTIHYPOGLYCEMIC (ORAL)

Agent of choice – carbohydrate

Antihypoglycemic agents will be useful in the management of

hypoglycemic reactions occurring in patient with diabetes mellitus or in the

non – diabetic patient with hypoglycemia.

44

Therapeutic Indications

Hypoglycemic state secondary to diabetes mellitus or forting

hypoglycemia (in conscious patient)

Slide Effects : Contraindications : Precautions

Oral carbohydrates should not be administered to patient who do not

have an active gag reflex or who are unable to dink without

assistance.

Parental antihypoglycemics should be administered in these

situations.

No side effects

Small tubes of decorative icing are useful in the management of

unconscious hypoglycemic individuals. These tubes contain a

thickened posts of concentrated sugar that can be applied in the form

of a ribbon to buccal mucosa

Availability : Glucola, gluco-stat, fruit juices, sugar, tubes of

BRONCHODILATING AGENT

Drug of choice : METAPROTERENOL – 1ST NON – CATECHOLAMINE

B- AGONIST

Alternative drug : Epinephrine, isoproteronol

Asthmatic patients and patients with allergic reactions manifested

primarily by respiratory difficulty will require the use of

bronchodilator drugs.

Although epinephrine remains the drug of choice in bronchospasm,

its wide ranging effects on system lead to introduction of more

specific agents. Metraproterenol a specific beta – 2

sympathomimetic has specific bronchial, smooth muscle relaxing

45

properties with little or no stimulatory effect on the cardiovascular

and gastrointestinal systems (beta 1)

In emergency situation in which the patients cardiovascular status is

unknown, beta – 2 stimulations appear more attractive for

management of acute asthmatic episode than agents such as

epinephrine and isoproterernol, which have both beta – 1 ad beta – 2

stimulating properties.

It will be in an inhalator that dispenses a calibrated dosage of the

medication. When the patient inhales as the agent is dispensed,

allowing the drug to reach the bronchial mucosa, where it acts

directly on bronchial smooth muscle.

One or two inhalations every hour is the maximal recommended

dosage.

Therapeutic Indications

Respiratory distress as seen in asthma.

Allergic reactions with primary respiratory phenomena.

Side effects : contraindications and precautions

Metraproterenol, epinephrine, isoproteronol has potential

cardiovascular side effects. Producing tachycardia, and ventricular

arrhythmias.

Contraindicated in patients with preexisting tachyarrhythmias

Availability :

Metraproterenol inhaler (alupent) :

Epinephrine mistometer (medihales – epi)

Isoproterenol mistometer (mediholar – 750)

46

EMERGENCY DRUGS

I. Cardiovascular emergencies – drugs used

1) Acute myocardial infarction

Aspirin therapy

Nitroglycerine

Analgesics –morphine sulphate

Streptokinase

2) Unstable angina

Aspirin

Nitrates

-blockers

3) Congestive heart failure

Vasodilators

Sodium nitroprusside

Digitalis

4) Hypertensive crisis

Nifedipine

Sodium nitroprusside

Nitroglycerine

Labetolol

Nicardipine

Esmolol

5) Shock

Fluid resuscitation

Vasopressors and inotropes

Dopamine

Dobutamine

47

6) Malignant hyperthermia

II. Respiratory :

1) Bronchial asthma : O2

Bronchodilators

Epinephrine

Systemic corticosteroids

2) Acute respiratory failure :

Bronchodilators

Corticosteroids

III. Neurological emergencies :

1) Status epilepticus – Anticonvulsant

Diazepam

Phenytoin

Phenobarbital

2) Stroke : transient ischemic attack

Antiplatelet therapy

Anticoagulant therapy

Heparin and Warfarin

IV. Endocrine emergencies

1) Thyroid crisis :

Antithyroid drugs – carbimazole

Antisympathetic drugs

Corticosteroids

48

2) Acute adrenal insufficiency

Vol replacement – 5% dextrose

Corticosteroids

3) Myxedema crisis :

Thyroid hormone – levothyroxine

Corticosteroids

V. Allergic reactions and syncope

Epinephrine

VI. Metabolic emergencies

Hypoglycemia

Diabetic ketoacidosis

49

CARDIOVASCULAR EMERGENCIES : DRUGS USED

I. ACUTE MYOCARDIAL INFARCTION :

1. ASPIRIN THERAPY :

Aspirin produces a rapid antithrombotic effect by inhibiting

cyclooxygenase and blocking formation of thromboxane A2 in platelets

almost instantly. The best way is to ask the patient to chew half to one tablet

(160-325 mg) of aspirin since buccal absorption of the drug is faster than

absorption through the gastric mucosa. Ideally should be administered

within 6 hrs of onset of symptom.

- Aspirin is acetylsalicylic acid. It is rapidly converted in the body to

salicylic acid which is responsible for most of the action.

Precautions and contraindications :

Aspirin is contraindicated in patients who are sensitive to it and in peptic

ulcer, bleeding tendencies.

An association between salicylate therapy and “Reyes syndrome”, a rare

form of hepatic encephalopathy seen in children having viral (influenza,

varicella) infection has been seen. So contraindicated in children.

In chronic lines disease cases of hepatic necrosis.

Uses :

1) As analgesic, antipyretic

2) Acute rheumatic fever

3) Rheumatoid arthritis

2) NITROGLYCERINE : VASODILATOR

50

Nitrates cause vascular smooth muscle relaxation by conversion to

nitric oxide.

This dilatation is more marked on the venous than the arterial side of

the circulation, so that myocardial preload is reduced proportionately more

than after load.

- Nitrates also dilate the coronary arteries, relieving spasm and

redistributing flow from epicardial to endocardial regions by opening

up collateral channels.

- Nitroglycerin sublingually in a dose of 0.3-0.4 mg and repeated every

3 min.

- Nitroglycerin acts in 1 to 2 min when placed sublingually.

Side effects : contraindications : precautions

Transient pulsating headache

Facial flushing

Contraindicated in hypotensive patients

Nitroglycerin also available in spray bottles.

3) ANALGESICS :

It is hear that the pain of AMJ is due to continuing ischemia of living

jeopardized myocardium rather than to the effects of completed myocardial

necrosis.

Morphine sulfate and pethidine hydrochloride are the two traditional

drugs used to control ischemic pain.

Used dose is 10-15 mg – morphine

If pain very intense IV in a dose of 2-5mg to be repeated 10-15 min

half the dosage,

- Total dose in 24 hrs should not exceed 60 mg morphine

51

Contraindications :

It is also useful to remember that morphine may produce hypotension

(due to venous pooling) and bradycardia (due to enhanced tone) and

therefore should be avoided if any of these complications is present or

anticipated, especially in inferior MI.

Morphine sulfate : Opioid agonist

Suggested for emergency kit :

Morphine sulfate, 10mg /ml (2 or 3 mg/ml ampules)

Treatment in the hospital

1. O2 Therapy : 3-4 lit / min

2. Thrombolytic therapy : – 3 thrombolytic agents

a) Streptokinase

b) Recombinant tissue plasminogen activator

c) Anisolyated plasminogen activator complex

Streptokinase : Is a non selective agent that induces a generalized

fibrinolytic state characterized by extensive fibrinogen degradation. Half

life- 30min. It is administered as an IV infusion of 1.5 million units over 60

min.

- Before starting streptokinase therapy 100mg hydrocortisone and 25mg

rhyriramine are administered IV to minimize risk of allergic reactions which

include fever, rash, hypotension.

3. - blockers : Atenolol or metaprolol (selective)

52

Therapy can be initiated with an IV bolus of metaprolol 5mg this dose

can be repeated a 5 min to a total dose of 15mg : with monitoring of vitals

signs.

4. Nitroglycerin : IV nitroglycerin 10 g / min

- blockers : IV - adrenoreceptor blockers given early in the course of

acute myocardial infarction reduce heart rate, BP and cardiac index, and

thus help to limit the infarct size, relieve chest pain and decrease risk of

ventricular arrhythmias.

Contraindications to -blockers : Hypotension

- In case of uncertainly regarding the safety of -blockade, an ultra short

acting -blocking agent (ESMOLOL) with half life of only 9min may be

used to determine whether the patient can tolerate beta blockade.

UNSTABLE ANGINA :

1) Aspirin therapy : In view of the widely accepted role of platelet

aggregates in the genesis of ischemic episodes in unstable angina,

aspirin is routinely prescribed.

The inhibitory effects of aspirin on platelet aggregation occurs

immediately and continue for 4-6 days after a single dose.

- Aspirin has been shown not only to relieve ischemic episodes

in unstable angina, but also to reduce the incidence of fatal and

non fatal MI

- A dose of 60-100mg – OD

- When aspirin contraindicated, TICLOPIDINE – 20mg BD

antiplatelet agents.

2) Nitrates : These are main stay in it of UA. By promoting coronary

blood flow nitrates not only relieve anginal pain and prevent its

recurrence, but also improves LV function.

53

- Can be given sublingually, orally, tonically or IV sublingual

nitroglycerin is available as 0.3, 0.4, and 0.6 mg tablets or

metered dose spray (0.4mg) usually 0.4 mg tablets are

prescribed.

- Peak pharmacologic action occurs within 2min

- Can be repeated at 5mm if symptoms persists.

3) -adrenergic blocking agents :

unless contraindications exists, 13 blockers should be combined with

nitrates in all cases of unstable angina, adjusting the dose so as to

maintain the heart rate between 50 – 60 beats / min. the combination

(nitrates and B blockers) not only reduces the frequency of recurring

ischemic episodes but also the occurrence of MI. even if the patient is

taking nitrates and calcium antagonists, blockers should be added.

- However, such patients should be carefully monitored since a

combination of -blockers and calcium antagonists (especially

veraparnil or diltiazm) may precipitate heart failure and / or

severe bradycardia.

Side effects :

- Bronchospasm, Postural hypotension, depression.

CONGESTIVE HEART FAILURE :

Main drugs are

1) Digitalis which augments myocardial contractility

2) Diuretics which reduce the preload of heart

3) Vasodilators which reduce elevated after load and decrease left

ventricular work.

54

These 3 groups of drugs are complementary to each other and are

used together in various combinations upon type and severity of HF.

Vasodilators : are main stay of TT in HF.

As venous and arterial vasoconstriction is important accompaniments

of CHF, vasodilators are now used extensively in HF.

The drugs currently employed most often are angiotensin – converting

enzyme (ACE) inhibitors which are “balanced vasodilators” having action

on venous and arterial beds.

ACE inhibitors, as a class, effectively antagonize the rennin –

angiotensin system and, by their direct action on peripheral vascular bed,

decrease the impedance (resistance) against which the heart pumps in heart

failure.

ACE inhibitors have revolutionized the it of CHF, and are now front

time drugs in management of HF both mild and severe.

Besides being potent vasodilator, such drugs have additional

properties beneficial in such patients.

1) Suppress angiotensin and aldosterone levels, and there by decrease

salt and fluid retention.

2) Reduce neurohormonal stimulation (catecholamine concentration)

and thus reduce the risk of sudden death.

3) Probably posses antianginal effect due to reduction in arterial

pressure without causing reflex tachycardia (thus lowering

myocardial oxygen demands).

ACE inhibitors not only relieve symptoms and improve

hemodynamic profile, but have also (the only drug) been found to improve

survival especially in cases with moderate and severe chronic HF.

55

TT may be started with any ACE inhibitor but in cases with

borderline BP, especially when on diuretic therapy, captopril or enalapril

may be safer because of their shorter duration of action.

Initial dose should be small (captopril 6.25mg; enalapril 2.5mg),

patient closely observed, and if there is no unusual drop in BP the next dose

may be doubled.

ACE inhibitors are generally safe, the only hazard being excessive

hypotension.

All ACE inhibitors are contraindicated in patients with intrinsic rend

disease, systemic hypotension.

Digitalis :

Digoxin : This should be used as first line therapy in patient with failure and

atrial fibrillation when it will usually provide adequate control of the

ventricular rate together with a small positive inotropic effect.

In emergency situation, 0.5 mg out of the total calculated dose should

be given IV slowly over 5-10 min and remaining by oral route over next 24

hours (rapid digitalization).

Digoxin toxicity :

- Gastrointestinal – Anorexia, nausea, vomiting

- SVS – bradycardia, ectopic beats.

- Miscellaneous – fatigue, headache, confusion, hallucination.

Diuretics :

Diuretics in one form or the other are always used in HF whenever

there is evidence of fluid retention.

When diuretics are initiated for an acute exacerbation of heart failure,

the goal of therapy should be a maximum net loss of 0.5-1.0 L of fluid / day

(0.5-1.0 kg body weight) to prevent intravascular volume depletion.

56

- When treating advanced / refractory cases of HF, high potency loop

diuretics. (furosemide and ethacrynic acid) are employed. Given IV their

diuretic action starts within 15min, peaks in about 30-45 min and lasts

for2-4 hours.

- Large single daily doses are to be avoided since by causing acute volume

depletion, such a regime is likely to activate resin – angiotensin

aldosterone system which may prove counterproductive and may

actually increase myocardial O2 demand.

- Thiazide diuretics (hydrochlorothiazide, chlorthiolidone) can be used as

initial agents in patients with normal renal function in whom only a mild

diuresis is desired.

Action : In heart failure diuretics produce an increase in urinary sodium

excretion, leading to a reduction in blood and plasma vol, and may also

cause a small but significant degree of arterial and venous dilatation.

Diuretic therapy will, therefore, reduce preload and improve pulmonary and

systemic venous congestion therefore it may also cause a small reduction in

after load and ventricular vol leading to a fall in wall tension and increased

cardiac efficiency.

HYPERTENSIVE CRISIS :

Hypertensive crisis is an all encompassing term which includes various

acute life-threatening situations associated with hypertension.

Conventionally classified as Hypertensive emergencies and hypertensive

urgencies.

Hypertensive emrgencies : are defined as a substantial increase in BP

usually with a diastolic BP of greater than 120-130 mm/sy.

- Accelerated – malignant hypertension.

- Perioperative hypertension.

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- Severe hypertension associated with

a) CHF

b) Stable angina.

c) Transient ischemic attacks.

Hypertensive emergencies include accelerated hypertension: defined as

systolic BP typically exceeding 210 and diastolic BP greater than 130

presenting with headache, blurred vision, and malignant hypertension.

- Hypertensive emergencies require immediate BP reduction (not

necessary to normal ranges) to prevent or minimize end-organ damage

i.e.

- Hypertensive encephalopathy

- Intracranial hemorrhage

- Unstable angina pectoris.

- Acute MI

- Acute LVF with pulmonary edema.

Immediate lowering of BP is required in these cases, and therefore

parenteral therapy is preferred. The aim should be to reduce mean pressure

(diastolic BP + 1/3 pulse pressure) to 120mm 14 or to lower mean pressure

by 20-25%k, over 30-90 min.

Initial therapy :

If there is likely to be some delay in instituting parenteral

antihypertensive therapy, nifedipine 5mg should be given sublingually. This

may reduce the BP by 10-20% of the pretreatment level.

Nifedipine is a calcium channel antagonist.

Action : is to cause arteriolar vasodilation by selective blockade of the slow

inward calcium channels in vascular smooth muscle cells.

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The effect starts within 1-5 min and is maximum at15-20min. Such rapid

reduction of BP is, however not without risk and therefore sublingual dose

should not exceed 5mg at a time.

Parentral drugs :

1) SODIUM NITROPRUSSIDE : It is most potent of the parenteral

hypotensive agents, with a rapid onset of action and immediate reversibility.

It also has minimal side effects. These qualities make it an ideal drug for

most of the hypertensive emergencies.

Action : It lowers the BP by primary vasodilation of both arterioles and

veins. Nitroprusside may therefore, increase pressure but still the best drug

in patients of hypertensive encephalopathy.

The drug is administered IV through an infusion pump at a rate of 0.25

to 0.5mg/kg/min, with constant monitoring of BP. The dosage is adjusted

according to BP response but should not exceed generally 3mg / Kg/min

and infusion not continued beyond 12 hours. At this risk of (cyanide

toxicity.

2) NITROGLYCERINE : it is a vasodilator, which given as a continuous

IV infusion may be appropriate in situations in which sodium nitroprusside

is relatively contraindicated, such as in patients with severe coronary

insufficiency or advanced send on hepatic disease.

It is preferred agent for patient with moderate hypertension because of its

more favorable effects on pulmonary gas exchange and collateral coronary

blood flow.

Nitroglycerin reduces preload more than after load, and should be used

in caution in acute MI.

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3) Labetolol : This is combined - blocker, bit - blocking properties

predominate clinically in the it of hypertensive emergencies. Marked

reduction in systemic vascular resistance results in lowering of BP with little

change in cardiac output or heart rate. Because of the associated betablocade

effect, the drug should be avoided in severe sinus bradycardia heart failure,

and asthma.

Labetalol : It bolus 20 – 80 mg every 10 min.

Onset – 5 – 10 min.

Duration of action – 3 – 6 hrs.

Its infusion :- 2 mg / min

4) Nicardipine : are effective IV calcium antagonist. Used for it in post –

operative hypertension and when given IV are as effective as nitroprusside

in rapidity of antihypertensive action. There is little change in heart rate, and

only a small increase in cardiac output, Nicardipine has apparently greater

selectivity for cerebral vessels and is perhaps the drug of choice in

management of cerebrovascular hypertensive emergencies.

Nicardipine : IV, 5 – 10 mg /

Action :- Continuous during infusion

5) Esmolol : Is a parenteral, short acting, cardio selective adrenergic

antagonist that can be used in it of hypertensive emergencies in patient

whom blocker intolerance is a concern.

- adrenergic antagonist may be infective when used as monotherapy

in case of severe hypertension and frequently combined with other agents

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SHOCK

Fluid resuscitation : usually is the 1st it used. All patients in shock should

receive an initial IV fluid challenge. The amount of fluid necessary is

unpredictable but should be based on changes in clinical parameters,

including arterial BP, urine output, cardiac filling pressures and Co.,

crystalloid fluid solutions (0.9 % NaCl or Ringer’s lactate) usually are

administered.

Blood Volume should be administered to patient with significant

anemia or active hemorrhage.

Vasopressors and Inotropes

DOPAMINE : (3 , 4 – dihydroxphenylethylamine) is immediate metabolic

precursor of norepinephrine and epinephrine. Like norepinephrine, it also

acts as both and adrenergic receptors, but imp difference is that the

effects are dose dependent.

When used in low doses ( 2- 5 mg / kg / min) it has a predominantly

beta – 1 adrenergic stimulant action on myocardial contractility and

therefore results in significant increase in stroke volume and cardiac output.

In this dosage it also produces vasodilation (promotes renal perfusion) and

lacks (the undesirable) chronotropic or peripheral vasoconstrictor effect of

norepinephrine with increasing doses, there is dose dependant increase in

chronotropic and - adrenergic vasoconstrictor effects with consequent

decrease in tissue perfusion.

At larger doses ( > 15 – 20 mg / kg/ min) its hemodynamic effects

come to resemble those of epinephrine with predominant chronotropic and

adrenergic stimulant action. Accordingly, systemic vascular resistance

(after load) increases and this coupled with tachycardia may aggravate

myocardial ischemia.

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In cases with cardioagenic shock, dopamine infusion should be

started at a low dose ( 2- 5 g / kg /min) to improve cardiac output and renal

perfusion and the dose carefully increased to maintain a systolic 13 p of 90

– 100

8) Dobutamine : This is a synthetic catecholamine with predominantly beta

– adrenergic agonist properties which amount for its inotropic and

chronotropic effects. Unlike dopamine, it lacks any appreciable beta –

adrenergic agonist action, and therefore, has little effect on systemic

vascular resistance even at larger doses. In the case of cardiogenic shock it

has therefore near ideal vasopressor properties. However when compared to

dopamine, it lacks renal vasodilator action. It should not therefore, be used

alone in the severely hypotensive patient rather it should be given

simultaneously with dopamine infusion. Used in this manner, dobutamine

may reduce dopamine requirement, and thus pharmacologically the best

possible improvement in hemodynamic profile viz., increase in stroke

volume and cardiac output, and reduction in left ventricular filling pressure

with only minimal increase in heart rate, peripheral vascular resistance and

myocardial O2 requirement.

9) Norepinephrine : It is a powerful catecholamine producing both and

– adrenergic stimulation, and used to be the mainstay of patient of

(cardiogenic) shock before the availability of dopamine. Though its –

adrenergic stimulation (which predominates) it acts as a potent

vasoconstrictor (increases afterload) while through the – adrenergic

stimulation it has relatively modest (myocardial) inotropic and chronotropic

effects.

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All these pharmacological actions result in increased myocardial O2

demand and hence are likely to worsen myocardial ischemia.

Norepinephrine is therefore now notused in cardiogenic shock.

MALIGNANT HYPERTHERMIA

Obtundation and muscular rigidity characterize malignant

hyperthermia syndrome.

- Serums creative kinase is markedly elevated.

- Multiple genetic mutations are associated with malignant

hyperthermia syndrome, with a likely common abnormal elevation in

intracellular calcium, following triggering factors (e.g. halothane

anesthesia)

Management - Discontinuation of offending anesthetic agent, aggressive supportive

care that focuses on oxygenation, ventilation, circulation, correction

of acid – base and electrolyte derangements and dantrolene sodium, 1

– 10 mg / kg / day, to reduce muscular rigidity.

RESPIRATORY EMERGENCIES – DRUGS USED

BRONCHIAL ASTHMA

1) Supplemental O2

2) Bronchodilators : are first line of it is an asthma attack and act by

relaxing the smooth muscle in all always.

- When given by nebulizer beta 2 agonist constitute the first line of

therapy of acute sever asthma. 1 or 2 ampoule of salbutamol 2.5 – 3

mg or terbutaline 5 – 10 mg should be given initially and should be

neubulized even 30 min.

- Intermittent aerosol it with salbutamol 2 – 5 mg should be continued

every 4 hrs.

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- When beta-2 agonists cannot be mobilized (e.g. patients on

mechanical ventilation), Terbutaline should be used SC in a dose of

0.25-0.5 mg every 6-8 hours.

Additional Bronchodilators : Include anticholinergics (ipratopium

bromide) and theophyllines. Though less potent that beta agonist, these are

invariably used in management of ASA.

Ipratopium bromide is particularly useful in patients with

bronchospasm induced by beta blockers or when acute asthma is

exceptionally severe.

b) EPINEPHRINE (Adrenaline) : This is a non selective -adrenergic

agonist and is associated with a high incidence of cardiovascular side effects

due beta-1-adrenergic receptor stimulation. However since the drug is a

powerful bronchodilator, a trial is worthwhile, and 1ml of1:1000 adrenaline

hydrochloride may be injected SC slowly in 2 or3divided doses 15 minutes

apart provided the patient is not over 40, and does not have already

tachycardia.

- Avoided in patients with cardiac disease, hypotension, hyperthyroidism or

diabetes.

3. Systemic corticosteroids :

Corticosteroids control airway wall inflammation by inhibiting

release of mediators from macrophages and eosinophils (but not from most

cells). Corticosteroids thus block the late phase reaction and subsequent

hyper-responsiveness.

Additionally, steroids decrease mucus production and are mucosal

edema resulting from microvascular leakage in the air ways.

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ACUTE RESPIRATORY FAILURE

- 1st relief of bronchoconstriction

- maintaining acceptable level of PaO2 and PaCO2

- Control of infection.

1) Bronchodilators : Best given by nebulizer every 2-45 hours.

- oral administration may aggravate tachycardia, and produce tremor

and tachyphylaxis.

- Parenteral beta- agonists are rarely indicated

- Anticholinergic drugs are also beneficial.

2) Corticosteroids

3) O2 Therapy

4) Antibiotics

NEUROLOGICAL EMERGENCIES :

STATUS EPILEPTICUS

ANTICONVULSANTS

1. DIAZEPAM (Calmpose) : very rapid action when given IV, and drug

of choice in instant control of seizures. Adult dose 0.2mg/kg IV at rate of

5 mg /min. Because of short action, it should be followed by phenytoin

to prevent recurrence of seizures. Diazepam must be given IV because

when administered by IM route, it does not have anticonvulsant action.

If parental preparation of lorazepam is available, it is preferable (over

diazepam), in the initial management of convulsive status since, being fewer

lipids soluble, it has a longer effective anticonvulsant half life.

IV dose of lorazepam is 0.1 mg/kg administered at a rate of 2mg

/min.

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2. PHENYTOIN (Dilantin) : After IV diazepam has terminated the

seizure, phenytoin should be given IV to prevent its recurrence, or to

control status epilepticus in case it persists following diazepam.

The used adult dose in adults is 15-20 mg/kg (not glucose containing

solution in which phenytoin precipitates) and administered gradually at rate

not exceeding 50mg / min.

Advantages of Phenytoin are

- High effectiveness in controlling convulsions,

- Relatively long half-life and its lack of CNS depression.

Side effects : -

- Hypotension

- Cardiac arrhythmia : therefore BP and ECG- monitored.

- IV phenytoin is contraindicated in patients with heart block or

severe myocardial disease.

- Phenytoin should not be given 1m since it is poorly absorbed.

3. PHENOBARBITAL : long acting. If the patient continues to have

seizures 15-20 min after the loading dose of phenytoin, (5-10 mg/kg of

phenytoin), Phenobarbital should be given IV 10mg/kg at a rate of 50-

100 mg / min. If the seizure still continue, a similar dose can be repeated

(upto total dose of 20mg/kg).

Note : When diazepam and phenobarbitone are used simultaneously or

sequentially, the patient must be intubated (for emergency ventilation) as

this combination may result in respiratory depression and even respiratory

arrest.

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CEREBROVASCULAR CATASTROPHES / ACCIDENTS (CVA)

Acute vascular disruption to a specific region of the brain

(“STROKE”) constitutes one of the emergencies encountered

Stroke encompasses several entities with vastly different clinical

presentation all of which arise from either lack of blood supply (ischemia)

or leakage of blood outside the normal vessels (Haemorrhage) stroke can be

classified as pathophysiological basis into 2 broad categories – Ischemic

stroke, Haemorrhagic stroke.

Transient ischemic attacks :

1) These comprise briefly and transient episodes of focal dysfunction of the

brain, without any clinical sequelae. The symptoms came suddenly, reach

the peak within a few seconds or a few minutes and are generally over in

less than half an hour. On some occasions, TIA may continue for several

hours through seldom more than 24 hours. Such transient ischemic episodes

are through to result from either an intermittent decrease in perfusion in an

area of the brain (“Low flow” with inadequate collateral circulation) or from

embolization of platelet fibrin material from heart or from atherosclerotic

lesions in large arteries in neck (artery to artery embolus)

1) ANTIPLATELET THERAPY

Aspirin is now universally accepted as the most effective drug

available to prevent TIA’s as well as to reduce the incidence of subsequent

stroke. It has been shown that Aspirin produces a rapid antithrombotic effect

by inhibiting cyclooxygenase and blocking formation of thromboxane A2 in

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platelets almost instantly, when given in small doses than in large doses. A

common dose is 325 mg/day.

The combination of aspirin (25mg bid) and extended release dipyridamole

(200mg bid) may be more effective in stroke prevention after TIA.

Dipyridamole is a vasodilator that in combination with aspiration reduces

thrombosis in patient with thrombotic disease.

8. Patient who cannot tolerate aspirin should be prescribed

TILOPIDINE. This newer antiplatelet agent prevents platelet

aggregation by inhibiting fibrinogen binding on to the platelet

membrane.

9. However the drug carries a small rise of producing leucopenia and

rash.

2) ANTICOAGULANT THERAPY : Therefore Heparin and warfarin

controversies.

Heparin anticoagulant effect of Heparin is medicated by an endogenous

component of plasma termed heparin factor. Patient has not yet been firmly

established that anticoagulation effectively reduces the stroke after TIA.

RENAL EMERGENCIES :

PRINCIPLES OF MANAGEMENT

1) Identification and several of underlying cause.

2) Fluid management

3) Control of Electrolytes

4) Acid base homeostasis.

5) Maintenance of nutrition

6) Institution of dialysis.

ENDOCRINE EMERGENCIES :

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THYROID CRISIS :

Aim

1) Inhibit both hormone synthesis and release.

2) Suppress the sympathetic aspect of paripheral

3) To control precipitating factor.

1) Antithyroid drugs : These are required to block thyroid hormone

synthesis and release. Thyroid hormone synthesis is achieved by use of

carbimazole (Neomercazole) 60-80 mg or propylthiouracil 600-100 mg

daily in divided doses orally or through Ryles tube if oral medication is not

possible.

-Propylthiouracil also blocks peripheral conversion of T4 to T3, - disease

– is these drugs may take about a week to lower serum T3 level.

-To inhibit hormone release. Iodine should be given in large doses IV. In

emergent situations, iodine can be given IV as sodium iodide, 0.5-1.0 g

in one litre of normal saline every 8-12 hours for 24 hours.

-An alternative approach is to administer iodinated X-ray contrast agent,

sodium ipodate, instead of iodide. It has additional advantage of

inhibiting peripheral conversion of T4 to T3.

2) ANTISYMPATHETIC DRUGS : -blockers often give dramatic

results decreasing heart rate within 2-3 hours when given orally, and within

minutes when given IV.

To relieve symptom of hyperthyroidism such as palpitations humor

and anxiety.

Propranolol 1-3 mg given slow IV and repeated 1mg after 3-4 hours.

During this patient should be loosely observed for pulmonary edema,

bronchospasm.

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3) CORTICOSTERIODS : Since biological half-life of cortisol is

sheltered and adrenocortical reserve is reduced in thyrotoxic crisis, large

doses of corticosteroids should be given

E.g. Hydrocortisone 200 mg IV initially, forward by 100 mg every 6

hours.

ACUTE ADRENAL INSUFFICIENCY :

- Key element in it is speed of action, replenishment of intravascular volume

and administration of corticosteroids.

1) Volume replacement :

Severe volume depletion, hyponatremia and hypoglycemia invariably

exist together in acute adrenal insufficiency. The fluid deficit often exceeds

6% of body weight. 5% dextrose in normal saline is fluid of choice and

should be infused at an initial rate of 500-1000 ml/hr. therapy guided by

hourly record of pulse, BP.

2) Corticosteroids : Hydrocortisone provides the best steroid replacement

as it contains both glucocorticoid and mineralocorticoid activity. An initial

dose of 200mg IV over 3-5 min should be followed by 100mg (1.5mg/kg)

every 6 hours. IV should be continued for 24 hours after recovery from

adrenal crisis. Thereafter prednisolone in daily dose of 20-40 mg.

3) Other measures : If hypotension – vasopressors such as Dopamine.

MYXEDEMA CRISIS :

1) Thyroid hormone : For quick improvement in thyroid status, it

should be started with levothyroxine IV in a loading dose of 200-400

microgram followed by 50-100 microgram IV daily until oral therapy

can be relied upon.

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2) Corticosteroids : Adrenal corticosteroids have been found deficient

in myxedema coma and therefore, should be replenished especially if

hypotension is a problem. For this purpose 200 mg hydrocortisone

should be given IV initially followed by 100 mg 3-4 times daily.

3) Rewarming: Hypothermia.

AILERGIC REACTIONS

Regardless of the cause, prompt treatment of anaphylactic and

anaphylactoid reaction is mandatory, since death may occur within minutes

or hours after the onset of 1st symptom.

The specific drug fro all such reactions is EPINEPHRINE. It prevents

continued mast cell activation, reduces mast cell mediator release and

reverse the action of mediators on target tissues.

If hypersensitivity is acute and generalized but not life threatening

(eg. pruritis, or urticaria, laryngeal edema, acute bronchospasm). 0.3-0.5ml

of 1:1000 epinephrine should be given SC and repeated 2 or 3 times at 5-7

minute intervals as required.

In cases who develop shock, SC epinephrine is not enough. Such

cases should be given 0.3ml epinephrine IV diluted 1:50,000 along with

volume expanders and vasopressors (dopamine) is intractable hypotension

develops.

Other measures is antihistamine IM and (when severe bronchospasm

exist) IV aminophylline.

SYNCOPE :

10.Trendelenburg position and 100% O2.

11.Spirit of ammonia may be placed under right nose. This noxious odor

stimulates the respiratory and vasomotor centers of the medulla.

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HYPOGLYCEMIA :

1) Autonomic (or neurogenic) symptoms : Include sweating,

palpitation, and hunger. Increased secretion of counter-regulatory

hormones (e.g. Epinephrine) account for these symptoms.

2) Neuroglycopenic symptoms : develop as blood glucose decreases

further include impaired concentration, irritability, blurred vision,

lethargy, and development of Seizure or lama.

TT:

1) Readily absorbable carbohydrates : (e.g. Glucose, and sugar

containing beverages ) can be administered orally to conscious

patients for rapid effect. Hypoglycemia associated with a carbose or

miglitol therapy should be preferentially be treated with glucose,

because these -glucosidase inhibitors block the digestion of

disaccharides and complex carbohydrates.

2) IV Dextrose : Is indicated for severe hypoglycemia, in patients with

altered consciousness, and during restriction of oral intake. An initial

bolus 20-50 ml 50% dextrose, should be given immediately followed

by infusion of D5 to maintain blood glucose above 100 mg/dl.

3) Glucagon : 1mg / ml (or SC) is an effective initial therapy for severe

hypoglycemia in patients who are unable to maintain oral intake or in

whom on an IV access cannot be secured immediately.

DIABETIC KETOACIDOSIS AND COMA :

Specific measures :

1) Fluid therapy: Severe dehydration (due to osmotic diuersis) is an

important accompaniment of DKA and needs to be managed aggressively.

72

The usual fluid deficit is 4-6 liters (80-100 ml/kg body weight) IV

fluid therapy should be started.

Initially 1 liter of fluid –1st hour followed by 250-500 ml / hr. for next

24 hours. Until BP is stabilized.

Thereafter, 1 liter of fluid – every 4 to 6 hours for 24 hour.

Type of fluid :

12.Normal saline solution is the fluid of choice in the initial stages as it

quickly restores intravascular volume and avoids a rapid fall in

extracellular osmolarity.

PRACTICAL APPROACH : As soon as DKA is diagnosed 20-40 units of

soluble insulin should be given, half IU and half IM, depending upon one

severity and duration of ketosis and the degree of impairment of

consciousness.

Note : SC insulin should never be used in DKA. It is slowly absorbed and

has a long half life (about 4 hrs), so there is a delay in onset of action.

IM insulin should be given in deltoid muscle (not in glutted lesion)

73

REFERENCES :

1. medical emergencies in the dental office,

Malamed

2. The pharmacological basis of therapeutics

Goodman and Gillman’s

3. Essentials of Medical Pharmacology

K.D. Tripathi

4. Washington Manual of Medical Therapeutics

5. Pharmacology and Pharmacokinetics

Satoskar and Bandarkar

6. Principles and Practice of Medicine

Davidson’s

7. Medical Emergencies in General Practice

SP Gupta and Dinesh K Gupta

8. Current Medical Diagnosis and Treatment

CMDT 2003.

9. OMSCNA- PHARMOCOLOGY- Vol 13, no. 1, Feb 2001.

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