DRUGS USED IN EMERGENCY

Introduction

Emergency medicine is the medical speciality dedicated to the diagnosis and treatment of unforeseen illness or injury. Emergency drugs are those chemical entities used in patients during life threatening conditions so that the symptoms can be controlled and life can be saved.Emergency drugs are usually available in those kind of dosage forms which have short onset of action for rapid effect.

The concept of GOLDEN HOUR

In emergency medicine, the golden hour (also known as golden time) refers to a time period lasting for one hour, or less, following traumatic injury being sustained by a casualty or medical emergency, during which there is the highest likelihood that prompt medical treatment will prevent death.It is well established that the patient's chances of survival are greatest if they receive care within a short period of time after a severe injury

Name a drug that should be present ALL emergency trays of every department of hospital ??????

PurposeTo provide initial treatment for broad spectrum of illness and injuries, most of which are life threatening.To save life of patient.To control symptoms of patient.To reach the site of action as soon as possibleTo normalize he vital body functions.To diverge the patient from possible risk.

OXYGEN

Without O2 brain death occurs within 6 minutes.O2 saturation is measured using pulse oximeter.In emergency condition O2 is required for severe physiological stress. Shock Traumatic injury Acute myocardial infarction. Cardiac arrest.

O2 is delivered using nasal mask or intranasal catheter.It is delivered through nasal cannula at the rate of 1-4 litre/ min ( 24 % )Through face mask the rate is 5-10 L/min.The oxygen is titrated according to SPO2. (when below 90 %.

Caution in cases of COPD patients as they may lose their hypoxic respiratory drive.

DRUGS FOR CARDIOVASCULAR SYSTEM EMERGENCIES

1) CORONARY PAIN SYNDROMES It is a group of conditions due to decreased blood flow

in the coronary arteries such that part of the heart muscle is unable to function properly or dies.

It refers to a spectrum of clinical manifestations associated with myocardial infarction and angina.

STABLE ANGINA Angina pectoris is pain, usually felt in the central chest,

which may radiate to the neck, both arms and occasionally, the back that occurs during exercise or

emotional stress and is rapidly relieved by rest. GLYCERYL TRINITRATE (GTN, NITROGLYCERIN)Dose : 0.5 mg Tablet is given sublingually every 5 min (max 3 dose)A potent vasodilator, nitro-glycerine relaxes vascular smooth-muscle beds. It works well on coronary arteries, improving blood flow to ischemic areas.

UNSTABLE ANGINAThis coronary syndrome is characterised by anginal pain which is severe, of recent onset, or which has recently become abruptly worse. Angina occurring at rest or following recent myocardial infarction is also classified as unstable angina

If pain is not relieved by GTN then infusion of NTG@

MORPHINE SULPHATE – Visceral Pain10-15 mg i.m or s.c or 2-3 mg i.v is given.Or TRAMADOLInjected i.v 100 mg tramadol is equianalgesic to 10 mg i.m morphine.

ASPIRIN Dose: 162-325 mg tablet It is given for chewing or diluted before administration

as soon as MI is suspected. Aspirin slows platelet aggregation, reducing the risk of

further occlusion or reclusion of the coronary artery or recurrent ischemic event.

Aspirin if diluted in a glass of water before given the disintegration time will be saved and faster action will be obtained.

MYOCARDIAL INFARCTIONComplete occlusion of a coronary artery leads to the death of the cardiac muscle it supplies.For pain relieve GTN or Morphine is given.Aspirin to limit the infarct size.Thrombolytic Therapy to dissolve the thrombi or emboli and recanalize an occluded vessel. Tenecteplase and Alteplase are preferred as their administration doesn't require prolonged i.v infusion.STREPTOKINASE : 1.5 million units i.v over 60 minutes.UROKINASE :2.5 lac unit i.v over 10 minutesALTEPLASE :15 mg bolus i.v followed by 50 mg within half an hour.TENECTEPLASE :i.v bolus of 0.53 mg/kg over 10 seconds

2)CARDIAC ARRESTCardiac arrest is a sudden stop in effective blood flow due to the failure of the heart to contract effectively.Defibrillation is the most prompt treatment.

ADRENALINEDose: 1 mg i.v bolus (1 ml of 1:1000) Adrenaline concentrates the blood around the vital organs, specifically the brain and the heart, by peripheral vasoconstriction.Adrenaline also strengthens cardiac contractions as it stimulates the cardiac muscle.

Amiodarone and Lidocaine are given to control arrhythmias.

3)CARDIOGENIC SHOCKCardiogenic shock is defined as a state where the cardiac output is inadequate to maintain tissue perfusion

DOPAMINEDose: 2-20 microgram/kg/min by i.v infusion.Preferred in patients with hypotension.Improve cardiac contractility.

DOBUTAMINEDose: 2-20 microgram/kg/min by i.v infusion.It is a beta1 agonist with prominent inotropic action.Dobutamine is preferred as it increases force of contraction without significant increase in HR.

4)CARDIAC ARRYTHMIASARRYTHMIA DRUG

Paroxysmal supraventricular tachycardiaAtrial tachycardia (150-200/min) with 1:1 A-V conduction.

ADENOSINE 6-12 mg rapid i.v injection.Causes membrane hyperpolarisation.

Atrial FlutterAtria beat at rate of 200-350/min and there is 2:1 or 4:1 AV block.

VERAPAMIL ± DIGOXIN OR AMIODARONEControl ventricular rate

Atrial fibrillationAtrial fibres are activated asynchronously at rate of 350-500/min associated with grossly irregular and often fast ventricular response.

i.v AMIODARONE100-300 mg over 30-60 minutes. Above mentioned drugs for vent. rate controlWARFARIN 2-5 mg oral or i.v

Ventricular Tachycardia4 or more consecutive ventricular exrasystoles

LIGNOCAINE i.v 50-100 mg bolus.Suppress VT and prevent VF

Torsades de pointesLife threatening form of polymorphic ventricular tachycardia with rapid asynchronous complex and an undulation ECG baseline.

MAGNESIUM SULPHATE 50% 2 gm i.v over 5-10 min.

Ventricular fibrillationIrregular, rapid and fractionalized activation of ventricles resulting in uncoordinated contraction of its fibres.

Defibrillation ± i.v AMIODARONE 100-300 mg over 30-60 minutes.

AV BlockDepression of impulse conduction through AV node and bundle of His.

ATROPINE 0.6-1.2 mg i.m if due to vagal over activity.ADREANLINE/ ISOPRENALINE in partial AV block

5)HYPERTENSIVE EMERGENSIESSystolic BP > 220mmhg or diastolic BP > 120 mmHg with evidence of active end organ damage.SODIUM NITROPRUSSIDEDose : 20-300 microgram/ min i.vBecause of predictable, instantaneous, titrable and balanced arteriovenous vasodilatory action it is preferred.Toxic in higher dose.GTN OR ESMOLOL can also be used. If injections nor available – Capsule Nifedipine S/L PHENTOLAMINE OR LABETALOL for hypertensive episode in pheochromocytoma, cheese reaction or clonidine withdrawal .LABETALOL foe pregnancy induced hypertension.

DRUGS FOR RESPIRATORY EMERGENCIES

1)ASTHMAAsthma is chronic inflammatory disease of the airways of the lungsStatus Asthmatics is an emergency condition where asthma attack is not relieved by relievers ( Bronchodilators)

SALBUTAMOLIt is beta-2 agonist and causes bronchial smooth muscle relaxation.100 – 200 microgram/puff. Such 2 puffs are inhaled through meter dose inhaler in case of breathlessness with the help of spacer.

In case of acute asthma- 2.5 mg SALBUTAMOL+ 500 microgram IPRATROPIUM BROMIDE repulse.Aerosolize respule solution by nebulizer and inhale through nose and mouth by face mask.IPRATROPIUM BROMIDE is anticholinergic and cause bronchodilation by blocking M3 receptor.

HYDROCORTISON HEMISUCCINATEDose: 200 mg given i.v immediately.Steroids improve airway, reduce asthma exacerbation.They also improve response of airway smooth muscle to beta2 agonist and reduce refractoriness to them.

AMINOPHYLLINE250mg/10ml ampoule to be dissolved in 20 ml of 5% glucose and is given i.v slowly.It causes smooth muscle relaxation.

2)EXACERBATION OF CHRONIC OBSTRUCTIVE AIRWAY DISORDERSALBUTAMOL to relieve breathlessness.Ipratropium bromide HYDROCORTISONE and AMINOPHYLINE given i.v for immediate effect.

3)EPIGLOTTITISEpiglottitis is a medical emergency and failure to provide prompt treatment may be fatal. It is due to infection of the epiglottis with Haemophilus influenzae bacteria. CEFTRIOXONEDose: 100mg/kg i.v immediately

4)PULMONARY OEDEMAAcute pulmonary oedema is a medical emergency that requires prompt treatment. Oxygen, morphine, vasodilators and diuretics should be used.FUROSEMIDEDose: 40 mg i.v is given immediately.Intravenous furosemide has a beneficial vasodilatory action as well as being a powerful diuretic.

Inj. NITROGLYCERINE 25 mg in 50 ml normal saline slowly i.v if systolic BP > 100 mm Hg.DOPAMINE or DOBUTAMINE in case of cardiogenic shock.MORPHINE :- 2 mg i.v to reduce anxiety and dyspnea.

Mansi dhandhaliya

NEUROLOGIC

EMERGENCIES

Most seizures are self-limited and brief. Emergency drug treatment is only necessary if the seizures are prolonged (>5 minutes) or recurrent.

Initial treatment is to stop convulsions and maintain ABC

SEIZURES

ANTICONVULSANTS:

MEDAZOLAM:

Injection (solution for injection): 1 mg/ml;5 mg/ml (administered into the buccal cavity between the gum and cheeks by syringe)

DIAZEPAM

5 mg intravenous bolus and repeat every 2 minutes to a maximum dose of 20 mg.0.5 mg/kg per rectum (Intravenous solution can be used , if i.v. line is not assesed ). PLUS for seizures - Injection phenytoin 15 mg/kg via intravenous infusion over 20 minutes followed by maintenance dose.

b. Thiopentone infusion – For status epilepticus

Thiopentone :5 mg/kg intravenous bolusLorazepam:4 mg injected i.v. at the rate of 2mg/minFosphenytoin:100-150 mg/min i.v. infusion to a maximum of 1000 mgPhenytoin sodium:Injected at the rate of 25- 50mg/min.Phenobarbitone sodium:50-100mg/min i.v. injection to a maximum of 10mg/kgInjection Valproate :5 mg/kg intravenous bolus

TETANUSa) Tetanus immune globulinThis substance neutralizes circulating toxin. Give tetanus immune globulin 4000 units intravenously over 30 minutesb) AntimicrobialsGive benzylpenicillin 100,000 units/kg (maximum dose 2.4 million units) intravenously every 4 hours.OR if penicillin sensitive give metronidazole 7.5 mg/kg (maximum dose 500 mg) intravenously every 8 hoursc) Morphine and diazepam used to control muscle spasms.

MENINGITIS:Bacterial meningitis is a medical emergency and antibiotic therapy should not be delayed if there isdifficulty in obtaining a CSF sample. In such cases, empirical therapy should be started immediately.

a) Empirical therapy Penicillin G 1.8 g (3 megaunits) intravenously

4-hourly for 10 daysplus chloramphenicol 750 mg – 1 g intravenously 6-hourly for 10 daysIn patients hypersensitive to penicillin: Chloramphenicol alone OR Ceftriaxone 4 g intravenously daily in one or two divided doses

b) Specific therapy

Pneumococcal/Neisseria meningitidis meningitis• Penicillin G 1.8 g (3 mega units) intravenously 4-hourly.

•In penicillin hypersensitive patients: Ceftriaxone 4 g intravenously daily in two divided doses.

Gram negative bacterial meningitis and cryptococcal meningitis give ceftriaxone and gentamicin.

ENDOCRINE EMERGENCIES

DIABETIC KETOACIDOSIS

It is characterized by hyperglycaemia, ketosis and acidosis.

a) Airway and breathing All patients should be given oxygen via a

face mask. Nasogastric tube is recommended to limit

regurgitation and aspiration.

b) Intravenous FluidsInitially fluid resuscitation should be with largevolumes of normal saline.When the blood glucose falls to below ( 300 mg %) i.e. 15mmol/l then the fluid should be changed to 5% dextrose or dextrose-saline.( Reason – To clear ketone from blood)c) Insulin

Intravenous bolus dose of 10 units short-acting regular insulin followed insulin intravenous infusion @4 units/hour.

d) Electrolytes

Potassium : intravenous potassium at a rate of 10-20 mmol/hour .Bicarbonate : It is only given when the blood pH is less than 7.0. Treatment of underlying cause

Hyperosmolar hyperglycaemic state (Non Ketotic)The treatment is similar to that in DKA .

ADRENAL INSUFFICIENCYa) Intravenous fluidsUse normal saline to correct hyponatraemia and dehydration:• Give 0.9% saline 1000 ml intravenously over 1 hourTHEN• Give 0.9% saline 1000 ml intravenously over 2 hours.b) Corticosteroids

Give hydrocortisone 200 mg intravenous bolus then give 100 mg every 6 hours

HYPOGLYCAEMIA

If the patient is conscious and able to swallow, give a sugary food or drink. If the patient is unable to swallow or unconscious at home, give sugar paste or honey into the mouth and transfer immediately to the nearest health care facility for intravenous glucose therapy.Give dextrose 50% 50 ml intravenously followed by continuous intravenous infusion of 5% dextrose for up to 24 hours.

THYROID STORM

a) Intravenous fluids Dehydrated or shocked patients should be

resuscitated with 0.9% saline.b) Beta-adrenergic antagonists Give propranolol 0.5 mg intravenous bolus every 2 minutes to a maximum of 10 mg using control of tachycardia (pulse <100 beats/minute) as an endpoint.(Cardiac monitoring is desirable.)c) Antithyroid drugs Give carbimazole 100 mg via nasogastric tube then

20 mg every 8 hours.

MYXEDEMA COMA (HYPOTHYROID CRISIS)a) Intravenous fluidsDespite their oedematous appearance, most patients have intravascular fluid depletion. This should be corrected by careful administration of 0.9% saline intravenously. Monitoring of central venous pressure and urine output is essential.b) Corticosteroids Give hydrocortisone 200 mg intravenously stat

then 100 mg intravenously 6-hourly.

c) Thyroid hormoneGive thyroxine 5 microgram/kg via nasogastric tube as a single dose then 50 microgram per day rising to 100 microgram daily after 7 days.Injection T3 -  20-mg loading dose to be infused over 30 min (Take caution of Arrhythmia)

PHAEOCHROMOCYTOMA

Give labetalol 0.2 mg/kg intravenously and repeat every 10 minutes OR infuse labetaloluntil the paroxysm ends or the blood pressure is stable.

TREATMENT FOR SPECIFIC POISON

1. OPIATES EX.- codeine, heroin, pethidine, morphine,

methadone. These drugs cause depression of conscious state and hypoventilation. Particular attention should be paid to the maintenance of the airway and adequate ventilation.

SPECIAL ANTIDOTE• Give naloxone 0.4 mg intravenously or intramuscularly and repeat in 5 minutes if necessary to a maximum of 2 mg.

2. PARACETAMOL :-

minimum toxic dose is 150 mg/kg and almost all patients who ingest more than 350 mg/kg will develop hepatic failure.

SPEACIAL ANTIDOTE • Give acetylcysteine 150 mg/kg intravenously over 15minutes

THEN

• Give acetylcysteine 50 mg/kg intravenously over 4 hours

3.ORGANOPHOSPHATE

SPECIAL ANTIDOTE

• Give atropine 2 mg intravenously every 10 minutes till dryness of mouth or other signs of atropinazation apear ( max. 200 mg in administred in a day ) • Pralidoxime 1 g intravenously over 30 minutes and repeat every 12 hours if symptoms persist. ( 500 mg / hour ) ( Muscle power – Neck muscle )

4. ORAL ANTICOAGULANTS EX.- WARFARIN , RAT POISON Overdose of these substances causes prolongation of the prothrombin time and increased risk of bleeding. SPECIFIC ANTIDOTE Give vitamin K 10 mg intramuscularly dailyPLUS if necessary (i.e. active bleeding or at high risk because of for example known active peptic ulcer)

Give fresh frozen plasma 2 units intravenously and repeat as necessary to a maximum of 8 units using repeated measurement of the prothrombin time as a guide to therapy

5.BETA-ADRENERGIC ANTAGONISTSEX.- PROPRANOLOL , ATENOLOL

SPECIAL ANTIDOTE Give adrenaline infusion 10 micrograms/minute and increase by 5 micrograms/minute

every 2 minutes until the systolic blood pressure is >90 mmHg, to a maximum of 100micrograms/minute

6. IRON Overdose of iron initially causes vomiting, diarrhoea, abdominal pain and sometimes haematemesis. After a variable quiescent period during which these gastro-intestinal symptoms resolve, the patient may develop shock and hypoglycaemia plus cardiac, hepatic and renal failure. SPECIAL ANTIDOTE The specific antidote is desferrioxamine but supportive care including intravenous fluid and glucose (if necessary) is important as well.Give desferrioxamine 15 mg/kg per hour by intravenous infusion continued until the patient is asymptomatic (usually 12 to 24 hours)

7. ASPIRIN This commonly used drug can be highly toxic in overdose. The toxic dose is greater than 150 mg/kg.Rx-Give 0.9% saline (or 0.3% saline with 3% dextrose in children) intravenously at a rate necessary to maintain a urine output greater than 2 ml/kg per hour PLUSGive sodium bicarbonate 1 mmol/kg intravenously every 4 hours to maintain a urine pH greater than 7.5 PLUSGive potassium chloride 0.25 mmol/kg intravenously over at least one hour, every 4 hours to maintain serum potassium levels > 4 mmol/l

8. DIGOXINDigoxin toxicity causes following condition... VENTRICULAR TACHYCARDIARx - phenytoin 15 mg/kg intravenously - magnesium sulphate 50 mg/kg intravenously

(maximum dose 5 g) over 5 minutes BRADIARRYTHMIAS Rx - atropine 10 microgram/kg intravenous

HYPERKALEMIA

Rx - short-acting insulin 10 units intravenous bolus - Give 50 ml of 50% glucose intravenously over

five minutes -sodium bicarbonate 100 mmol intravenously over

five minutes

9.TRICYCLIC ANTIDEPRESSANTS (e.g. amitriptyline, doxepin, imipramine)

Rx – (a) for seizure

• Give diazepam 0.1 mg/kg intravenous bolus and repeat in 5 minutes if necessary

For hypotension

- Give 0.9% saline 10 ml/kg intravenous bolus THEN if hypotension persists•Give sodium bicarbonate 1 mmol/kg intravenous

For Ventricular tachycardia

• Give sodium bicarbonate 1 mmol/kg intravenous bolus THEN if arrhythmia persists• Give Lignocaine 1 mg/kg intravenous bolus

11. METHANOL POISONINGA blood level of >50mg/dl methanol is associated with sever poisoning.FATAL DOSE :- 75-100 ml

SPECIAL ANTIDOTE

Administer ETHANOL ( 10% water ) through a nasogastric tube; loading dose of 0.7 ml/kg is followed by 0.15 ml/kg/hour.

ANTIDOTES

1.AMYL NITRITE INDICATION:- Cyanide poisoning

2. BENZATROPINE (MESILATE )

INDICATION :- Dystonic reaction cause by antipsychotic drug or metoclopromide.

3. CALCIUM DISODIUM EDETATE

INDICATION :- Poisoning with metals , especially lead

4. CALCIUM GLUCONATE

INDICATION :- (1) Hydrofluoric acid skin burn (2) Poisoning with CCB

5.DIMERCAPROL

INDICATION :- Poisoning with arsenic mercury lead

6. FOMEPIZOLE

INDICATION :- Poisoning with ethylene glycol or methanol

7. FOLINATE – Calcium Leucoverin

INDICATION :- methotrexate rescue

8.FLUMAZENIL

INDICATION :- Reversal of benzodiazepine sedation in anasthetic , intesive care and diagnostic procedure

9.GLUCAGONINDICATION :- Poisoning with beta- adrenoreceptor blocking drugs.

10.PENICILLAMINEINDICATION :- Poisoning wth lead , copper , arsenic .

11. ISOPRENALINE INDICATION :- Hypotension or low cardiac output due to cardiotoxic drugs ( beta- adrenoreceptor drugs and CCB drugs )

12.PHENTOLAMINEINDICATION :- Severe hypertension caused by amphetamines , MAOIs , clonidine .

13. PHYTOMENADIONE ( vit.- k1 )INDICATION ;- poisoning with caumarin anticoagulants .

14. SODIUM NITRITEINDICATION :- Cyanide poisoning15. PYRIDOXIMEINDICATION:-Poisoning with isoniazid,Gyromeria species.

16. SODIUM BICARBONATEINDICATION :- Poisoning with salicylates , chlorophenoxy herbicides .

17. SODIUM 2,3-DMPSINDICATION :- Poisoning with metals especially mercury , arsenic , bismuth , copper .

18. SODIUM NITROPRUSSIDEINDICATION :- Severe hypertension due to ergotamine , amphetamine , MAOIs19. SODIUM THIOSULPHATEINDICATION :- Cyanide poisoning

20. ATROPINE ( SULPHATE )INDICATION :- Organophosphate or carbamate insectiside poisoning .