EMERGENCY DRUGS IN HYPERTENSIVE EMERGENSIES
Systolic Blood Pressure More Than 220 mmHg or diastolic Blood Pressure More Than 120 mmHg with evidence of active end organ damage. Following Emergency drugs are used in hypertensive crisis.
- SODIUM NITROPRUSSIDE Dose : 20-300 microgram/ min i.v Because of predictable, instantaneous, titrable and balanced arteriovenous vasodilatory action it is preferred. Toxic in higher dose.And That’s The Reason Proper Monitoring Should Be Done.
- LABETALOL for pregnancy induced hypertension.
- ESMOLOL can also be used. If injection is not available Use Capsule Nifedipine S/L
- PHENTOLAMINE OR LABETALOL for hypertensive episode in pheochromocytoma, cheese reaction or clonidine withdrawal
EMERGENCY DRUGS FOR CARDIOVASCULAR SYSTEM EMERGENCIES
Following Emergency drugs are used in cardiovascular emergencies
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.
Angina pectoris is a throbbing pain, usually felt in the central chest, which may spread 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) ) A potent vasodilator, nitro-glycerine relaxes vascular smooth-muscle beds. It works well on coronary arteries, improving blood flow to ischemic areas.Dose : 0.5 mg Tablet is given sublingually every 5 min (max 3 dose)
This 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 GLYCERYL TRINITRATE GTN then infusion of NTG MORPHINE SULPHATE – Visceral Pain Dose Of 10-15 mg i.m or s.c or 2-3 mg i.v is given. Or TRAMADOL Injected i.v 100 mg tramadol is equianalgesic to 10 mg i.m morphine.
- ASPIRIN : 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. Dose: 162-325 mg tablet .Aspirin if diluted in a glass of water before given the disintegration time will be saved and faster action will be obtained.
Complete 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. Following Emergency drugs are used in MI,
- STREPTOKINASE : 1.5 million units i.v over 60 minutes.
- UROKINASE :2.5 lac unit i.v over 10 minutes
- ALTEPLASE :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
- NITROGLYCERIN) Dose : It Is A potent vasodilator, nitro-glycerine relaxes vascular smooth-muscle beds. It works well on coronary arteries, improving blood flow to ischemic areas.
Dose:0.5 mg Tablet is given sublingually every 5 min (max 3 dose)
It is defined as a state where the cardiac output is inadequate to maintain tissue perfusion. Following Emergency drugs are used in cardiogenic shock
- DOBUTAMINE : It is a beta1 agonist with prominent inotropic action.Dose: 2-20 microgram/kg/min by i.v infusion. Dobutamine is preferred as it increases force of contraction without significant increase in HR.
- DOPAMINE :Dose: 2-20 microgram/kg/min by i.v infusion. Preferred in patients with hypotension. Improve cardiac contractility.
ARRYTHMIA DRUG Paroxysmal supraventricular tachycardia Atrial tachycardia (150-200/min) with 1:1 A-V conduction.Following Emergency drugs are used in Cardiac Arrythmias,
- ADENOSINE 6-12 mg rapid i.v injection. Causes membrane hyperpolarisation. Atrial Flutter Atria beat at rate of 200-350/min and there is 2:1 or 4:1 AV block.
- VERAPAMIL ± DIGOXIN OR AMIODARONE Control ventricular rate Atrial fibrillation Atrial fibres are activated asynchronously at rate of 350-500/min associated with grossly irregular and often fast ventricular response.
- AMIODARONE (I.V) 100-300 mg over 30-60 minutes. Above mentioned drugs for vent. rate control
- WARFARIN 2-5 mg oral or i.v Ventricular Tachycardia 4 or more consecutive ventricular exrasystoles
- LIGNOCAINE i.v 50-100 mg bolus. Suppress VT and prevent VF Torsades de pointes Life 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 fibrillation Irregular, 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 Block Depression 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
Cardiac 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.
- ADRENALINE : 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.
Dose: 1 mg i.v bolus (1 ml of 1:1000)
EMERGENCY DRUGS FOR RESPIRATORY EMERGENCIES
Asthma is chronic inflammatory disease of the airways of the lungs And Status Asthmatics is an emergency condition where asthma attack is not relieved by relievers ( Bronchodilators). Following Emergency drugs are used in Asthmatics emergency
- SALBUTAMOL :It is beta-2 agonist and causes bronchial smooth muscle relaxation. Dose Of 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 HEMISUCCINATE : Steroids improve airway, reduce asthma exacerbation. They also improve response of airway smooth muscle to beta2 agonist and reduce refractoriness to them.Dose: 200 mg given i.v immediately.
- AMINOPHYLLINE :250mg/10ml ampoule to be dissolved in 20 ml of 5% glucose and is given i.v slowly. It causes smooth muscle relaxation.
EXACERBATION OF CHRONIC OBSTRUCTIVE AIRWAY DISORDER :
- SALBUTAMOL to relieve breathlessness. Ipratropium bromide HYDROCORTISONE and AMINOPHYLINE given i.v for immediate effect.
EPIGLOTTITIS .Epiglottitis 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.
- CEFTRIOXONE :Dose: 100mg/kg i.v immediately
PULMONARY OEDEMA:Acute pulmonary oedema is a medical emergency that requires prompt treatment. Oxygen, morphine, vasodilators and diuretics should be used.
- FUROSEMIDE :Dose: 40 mg i.v is given immediately. Intravenous furosemide has a beneficial vasodilatory action as well as being a powerful diuretic.
- NITROGLYCERINE (INJ) 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.
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 And 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.
- Thiopentone infusion – For status epilepticus :Thiopentone :5 mg/kg intravenous bolus
- Lorazepam:4 mg injected i.v. at the rate of 2mg/min
- Fosphenytoin:100-150 mg/min i.v. infusion to a maximum of 1000 mg
- Phenytoin sodium:Injected at the rate of 25- 50mg/min.
- Phenobarbitone sodium:50-100mg/min i.v. injection to a maximum of 10mg/kg Injection Valproate :5 mg/kg intravenous bolus
TETANUS a) Tetanus immune globulin :This substance neutralizes circulating toxin. Give tetanus immune globulin 4000 units intravenously over 30 minute.
- Antimicrobials :Give 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 hours c) Morphine and diazepam used to control muscle spasms.
MENINGITIS: Bacterial meningitis is a medical emergency and antibiotic therapy should not be delayed if there is difficulty in obtaining a CSF sample. In such cases, empirical therapy should be started immediately.
- Empirical therapy Penicillin G intravenously 4-hourly for 10 days plus chloramphenicol 750 mg – 1 g intravenously 6-hourly for 10 days In patients hypersensitive to penicillin: Chloramphenicol alone OR Ceftriaxone 4 g intravenously daily in one or two divided doses
If the patient is conscious and able to swallow, give a sugary food or drink. And 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.
DIABETIC KETOACIDOSIS :
It is characterized by hyperglycaemia, ketosis and acidosis. All patients should be given oxygen via a face mask. Nasogastric tube is recommended to limit regurgitation and aspiration.
Intravenous Fluids :
Initially fluid resuscitation should be with large volumes 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.
- 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)
MYXEDEMA COMA (HYPOTHYROID CRISIS)
- Intravenous fluids :Despite 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.
- Thyroid hormone :Give 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 labetalol until the paroxysm ends or the blood pressure is stable.
Following Emergency drugs are used in adrenal insufficiency
- Intravenous fluids :Use normal saline to correct hyponatraemia and dehydration: • Give 0.9% saline 1000 ml intravenously over 1 hour THEN • 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
- 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.
EMERGENCY DRUGS FOR TREATMENT OF SPECIFIC POISON
Following Emergency drugs are used in the treatment of specific poison
- OPIATES Example ;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.
- PARACETAMOL :- minimum toxic dose is 150 mg/kg and almost all patients who ingest more than 350 mg/kg will develop hepatic failure. SPEACIALANTIDOTE • Give acetylcysteine 150 mg/kg intravenously over 15minutes THEN • Give acetylcysteine 50 mg/kg intravenously over 4 hours
- SPECIALANTIDOTE • 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 )
- ORAL ANTICOAGULANTS For Example 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 daily PLUS 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
- BETA-ADRENERGIC ANTAGONISTS e.g 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 100 micrograms/minute
- 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)
- ASPIRIN :This commonly used drug can be highly toxic in overdose. The toxic dose is greater than 150 mg/kg. 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 PLUS .Give sodium bicarbonate 1 mmol/kg intravenously every 4 hours to maintain a urine pH greater than 7.5 PLUS .Give potassium chloride 0.25 mmol/kg intravenously over at least one hour, every 4 hours to maintain serum potassium levels > 4 mmol/l
- DIGOXIN Digoxin toxicity causes following condition.
Following Emergency drugs are used in specific emergency conditions
- VENTRICULAR TACHYCARDIA Rx – 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
- 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
- METHANOL POISONING A blood level of >50mg/dl methanol is associated with sever poisoning. FATAL DOSE :- 75-100 ml SPECIALANTIDOTE Administer ETHANOL ( 10% water ) through a nasogastric tube; loading dose of 0.7 ml/kg is followed by 0.15 ml/kg/hour.
- AMYL NITRITE INDICATION:- Cyanide poisoning
- BENZATROPINE (MESILATE ) INDICATION :- Dystonic reaction cause by antipsychotic drug or metoclopromide.
- CALCIUM DISODIUM EDETATE INDICATION :- Poisoning with metals , especially lead
- CALCIUM GLUCONATE INDICATION :- (1) Hydrofluoric acid skin burn (2) Poisoning with CCB
- DIMERCAPROL INDICATION :- Poisoning with arsenic mercury lead
- FOMEPIZOLE INDICATION :- Poisoning with ethylene glycol or methanol
- FOLINATE –Calcium Leucoverin INDICATION :- methotrexate rescue
- FLUMAZENIL INDICATION :- Reversal of benzodiazepine sedation in anasthetic , intesive care and diagnostic procedure
- GLUCAGON INDICATION : Poisoning with beta- adrenoreceptor blocking drugs.
- PENICILLAMINE INDICATION:- Poisoning wth lead , copper , arsenic .
- ISOPRENALINE INDICATION :Hypotension or low cardiac output due to cardiotoxic drugs ( beta- adrenoreceptor drugs and CCB drugs )
- PHENTOLAMINE INDICATION : Severe hypertension caused by amphetamines , MAOIs , clonidine . 13. PHYTOMENADIONE ( vit.- k1 )INDICATION ;- poisoning with caumarin anticoagulants .
- SODIUM NITRITE INDICATION : Cyanide poisoning
- PYRIDOXIME INDICATION:Poisoning with isoniazid,Gyromeria species.
- SODIUM BICARBONATE INDICATION :- Poisoning with salicylates , chlorophenoxy herbicides .
- SODIUM 2,3-DMPS INDICATION :- Poisoning with metals especially mercury , arsenic , bismuth , copper .
- SODIUM NITROPRUSSIDE INDICATION : Severe hypertension due to ergotamine , amphetamine , MAOIs.
- SODIUM THIOSULPHATE INDICATION :- Cyanide poisoning
- ATROPINE ( SULPHATE ) INDICATION :- Organophosphate or carbamate insectiside poisoning .
- In emergency condition O2 is required for severe physiological stress.Shock ,Traumatic injury , Acute myocardial infarction, Cardiac arrest.Without O2 brain death occurs within 6 minutes
- 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 And The oxygen is titrated according to SPO2. (when below 90 %. Caution in cases of COPD patients as they may lose their hypoxic respiratory drive.