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Drugs in Emergencies
Dr U I HapuarachchiDepartment of Surgery
Faculty of Medicine, Galle
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Learning objectivesAt the end of this lecture, you should be
able to demonstrate; Commonly used drugs
Indications
Routes of administration
Common adverse effects
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ContentVasoconstrictors
Anti-arrhythmic drugs
Inotropes
Vasodilators Opioid antagonists
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Adrenaline 1 mg/ml
1:1000 concentration
Brown colour ampoule
Mode of Action
& effects
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AdrenalineIndications
Cardiac arrest VF or Pulseless VT -iv
Anaphylaxis im or iv
Inotrope - iv
Laryngospasm - nebulization
Local infiltration with LAvasoconstrictor
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AdrenalineDose 1:1000 im anaphylaxis
1:10000 iv Anaphylaxis & cardiac arrest 1:200000 infiltration
0.05-0.5 g/kg/min - infusion
Side effects
myocardial O2 consumption
heart rate
Pro arrhythmic
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Vasopressin
20 iu/ml 1 ml clear ampoule
Mode of action Smooth muscle V1 receptor stimulation
Intense vasoconstriction
Indications
Septic shock resistant to other vasoconstrictors
Variceal bleeding
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VasopressinDose
0.03 iu/min as an infusion in sepsis
20 iu over 15 min in variceal bleeding
Side effects
Headache
Myocardial and peripheral ischaemia
Nausea & vomiting
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Amiodarone 150 mg/ml 2 ml ampoule
Brown colour ampoule
Mode of Action
Membrane stabilizing anti-arrhythmic duration of action potential & refractory period
Mild negative inotrope
blockage
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AmiodaroneIndications
VF or pulseless VT cardiac arrest just before4th shock
Unstable tachycardia (narrow/broad complex)
Stable broad complex tachycardia
Stable narrow complex tachycardia
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Amiodarone
Dose
300 mg bolus diluted in 20 ml of 5% Dextrose
(unstable- 10-20 min, stable 20-60 min) 900 mg infusion over 24 hours
Side effects
Hypotension & bradycardia
Prolonged use photosensitivity, abnormal thyroidfunction, peripheral neuropathy, pulmonary fibrosis,
hepatic dysfunction
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Atropine 1 mg/ml or 0.6 mg/ml vial
Clear colour ampoule
Mode of action
Blocks the parasympathetic neurotransmitteracetylcholine (anti-muscarinic)
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AtropineIndications
Cardiac arrest Asystole of PEA Bradycardia
With neostigmine in reversal of muscle paralysis
Antisialogogue
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AtropineDose
0.5 mg iv
0.02 mg/kg in reversal
Side effects Blurred vision, dry mouth
Urine retention
Acute confusion state
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Adenosine 3 mg/ml vial 2 ml
Mode of action
Naturally occuring purine nucleoside
transmission across AV node Extremely short half life 10-15 sec
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Adenosine
Indications
Stable narrow complex tachycardia notterminated by vagal maneuvers
Can be given in undiagnosed VT
If SVT - ventricular rate
If VT no change in ventricular rate
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Adenosine
Dose
6 mg > 12 mg > 12 mg in SVT
Side effects
Negative inotrope hypotension Nausea, flushing
Chest discomfort
Bronchospasm
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Verapamil
2.5 mg/ml 2 ml vial
Mode of action Slows conduction / refractoriness in AV node
Indications Stable narrow complex tachycardia not
terminated by vagal maneuvers / adenosine
Control of ventricular rate in patients with AF
or Atrial flutter
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Verapamil
Dose
2.5-5 mg iv over 2 min
Repeat 5-10 mg every 15-30 min
Maximum < 20 mg
Side effects
Headache, flushing
Hypotension due to myocardial contractility
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Digoxin
250 g/ml 2 ml vial
Mode of Action
vagal tone
sympathetic activity by suppression of
baroreceptors
Prolong AV node refractory period
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Digoxin
Indications
AF with fast ventricular rate
Side effects
Nausea, diarrhoea, anorexia Confusion, dizziness
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Digoxin
Toxicity increased by
Hypokalaemia
Hypomagnesaemia
Hypoxia
Hypercalcaemia
Renal failure
hypothyroidism
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Dobutamine
Mode of Action
1, 2 effects
Indications
Inotrope of choice in post resuscitation Useful when pulmonary oedema is
present
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Dobutamine
Dose
5-20 g/kg/min as infusion
Side effects
Tachycardia Arrhythmias
Exacerbate myocardial ischaemia
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Noradrenaline
Mode of action
Potent agonist
Mild effect
Indications Severe hypotension with low peripheral vascular
resistance
Septic shock
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Noradrenaline
Dose
0.05-0.5 g/kg/min as infusion
Side effects
Headache
Bradycardia
Arrhythmias
Peripheral ischaemia
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Dopamine
D1, D2, 1, 1 &2 effects
Dose 1-20 g/kg/min
Renal dose Dopamine ?
Indicated for hypotension in the absenceof hypovolaemia
May cause cardiac arrhythmias, myocardial O2 demand & worsen
ischaemia
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Naloxone
Used for opiate overdose
Competitive antagonist at opioid
receptors
Reverses all effects of opioids
Duration of action < opioids
Need frequent boluses or infusion
400 g/ml 1 ml vial
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Others
Calcium chloride
Ephedrine
Magnesium sulphate
Sodium bicarbonate
Beta adrenergic blockers Nitrates
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References
Bennett PN, Brown MJ.
Chapter 22- Adrenergic mechanisms & Drugs. ClinicalPharmacology- 9thEdition Pg 447-455
Bennett PN, Brown MJ.
Chapter 24- Cardiac arrhythmias & Cardiac failure. ClinicalPharmacology- 9thEdition Pg 497-513
Richards D, Aronson J.
Anti-arrhythmic drugs. Oxford Hand Book of Practical DrugTherapy Pg 77-103
Richards D, Aronson J.Adrenoceptor agonists & Anti-muscarinic Drugs. Oxford HandBook of practical Drug Therapy Pg 190-199
http://www.resus.org.uk
Guidelines, medical information & reports > Resuscitation
Guidelines 2005 > Adult & paediatric Advanced life Support
http://www.resus.org.uk/http://www.resus.org.uk/ -
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Thank You