Emergency Drugs and Its Uses

8/3/2019 Emergency Drugs and Its Uses

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Presented by : Dr. jigar thakkar


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CONTENTS

yIntroduction

y

Emergency drug kityRequirement of drug kit

yEmergency drug modules

or levelsyConclusion

y

References


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INTRODUCTION

y All staffs in dental practice must be trained

y All dental offices and the hospitals should maintain at leastthe basic recommended emergency equipment and drugs

y Course of medicine that include all possible conditionlike.seizures, chest pain and respiratorty difficulty etc.

y BLS [P-positioning, A-airway, B-breathing, C-circulation, D-definitive care]


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EMERGENCY KITSy Commercially available or designed

personally

y As simple as possible

y 3 things to be remembered

y Primary management of all emergencysituation involves BLS

y drug administration- not necessary forthe immediate M/o medical emergenciesexcept anaphylaxis

y When in doubt, never medicate


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Requirements of drug kits

y Dental office emergency kit should not becomplicated.

y Should be as simple as possible to use.y It is always best to use a drug with which clinician

is most familiar and comfortable.

y

Should not have too many drugs of similar types,because this leads to confusion and indecision.

y All drug package inserts should be kept in it.


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y Home made kits are always better as clinician will beaware of drug and equipment that should be includedin the kit.

y Select the kit which best fits the individual needs of

his office or augment the kit with separately purchaseditems.

y Drugs and equipments should be included as per theindividuals training.


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EMERGENCY DRUGSEmergency drugs

Module 1 Module 2 Module 3 Module 4

critical drugs

& equipment

non critical drugs

& equipmentACLS antidotal drugs

Injectable drugs and

Non-injectable drugs


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Injectable drugs and Non-injectable drugs

Most injectable emergency drugs: 1ml glass ampuleor vial. c/d as therapeutic dose- except epinephrine

infant one-quarter, Pediatric pt one-half than adult

dose

Non injectable drugs: one tablet or spray is adult

therapeutic dose.

Other items of emergency equipment should be

available in both pediatric and adult forms. E.g. face

masks, airways etc


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DMINISTRATION OF INJECTABLEDRUGS

y Enough of the inj drugsmust enter the blood stream and be transported

to the part of the bodywhere it is needed

y

Ideal route for emergency-IV- onset of actionapproximately 20 sec


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y

IM route- 10 minyVarious sites:

y Mid-deltoid region

y Vastus lateralis

y Gluteal regiony The tongue - Onset of

action - 5-10 min

y Endotracheal

route(when available)


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MODULE ONECritical emergency drugs and equipment

y Injectable drugs1) Epinephrine

2) Histamine blockers

y Noninjectable drugs1) Oxygen

2) Vasodilators

3) Bronchodilator

4)A

ntihypoglycemics5) Aspirin


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y Emergency equipment

1) Oxygen delivery system

2) Suction and suction tips

3) Tourniquets

4)

Syringes5) Magill intubation forceps


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MODULE TWO

yInjectable drugs

y Anticonvulsants

y Analgesics

y Vasopressors

y Antihypoglycemics

y Corticosteroids

y Antihypertensives

y Anticholinergics


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y Noninjectable drugs

y Respiratory stimulant

y Antihypertensives

y Emergency equip

ment

y Scalpel or cricothyrotomy needle

y Artificial airways

y Laryngoscope and endotracheal tubes


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MODULE THREEy Advance cardiovascular life

support(ACLS) essential

drugs

y Epinephrine

y Oxygen

y Lidocaine

y

Atropiney Dopamine

y Morphine sulphate

y Verapamil


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MODULE FOUR

y Anti dotal drugs

y Opioid antagonist

y Benzodiazepine antagonist

y Antiemergence delirium drug

y Vasodilator / local anesthetic


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MODULE ONECritical emergency drugs and equipment


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Primary injectable:drug for acute allergic reaction

BValuable in management of both

respiratory and cardiovascularmanifestation of acute allergicreaction.

B and agonistBProperties

BRapid onset action, bronchodilator,vasopressor action, histamine- blockingproperties

Baction on heart: HR, SBP, CO,coronary blood flow, DBP

Drug Of Choice : EPINEPHRINE

Drug class: catecholamine


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y Therapeutic indication:

y To treat cases of acute allergic reactiony Acute asthmatic attack

y Mangement of cardiac arrest 1:10,000

y precautions pregnant women

y availibility: in 2 concentrationy Suggested for emergency kit:

y 1 preloaded syringe [1ml of 1:1000 (1mgepinephrine)] and

y

3 to 4 ampules of 1:1000 epinephrine

1:1000


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Primary injectable:for allergic reaction (antihistamine)

Drug Of Choice : Chlorpheniramine

Drug class: Histamine Blocker

Alternative drug: Diphenhydramine

Competitive antagonists of histamine,

Chlorpheniramine is less sedative

than diphenhydramine

Therapeutic indication:

M/o delayed-onset allergic reactions

Definitive m/o acute allergic reaction

As Local anesthetics when the patient has h/o allergy to LA

MOA:


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y Side effects : CNS depression , BP, thickeningof bronchial secretion resulting from drugdrying action

y Contraindication: acute asthma

y Availability:y Chlorpheniramine 10mg/ml (1ml& 2ml ampules)

1ml preloaded syringes

y Diphenhydramine- 10 mg/ml (10 & 30ml multidose vial)

50 mg/ml(1ml & 10ml multidose vial

y

Suggested for emegency kit1 ml of 3 to 4 ampules


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Primary noninjectable :

oxygen(O2)y Most useful

y Supplied variety of sizes

y Recommended E cylinder

provide 02 for approx 30 minutesy Therapeutic indication

y In any emergency situation n whichRespiratory distress is evident,

like.y Contraindicated:

y Rxof hyperventilation

y Suggested for emergency kit


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Primary Noninjectable Drug - Vasodilator

y Drug Action:y Coronary and systemic vasodilator - decreases

peripheral vascular resistance and preload

y Decreases cardiac workload and oxygen demandon the heart

y 2 varieties of available: tab and sprayy Amyl nitrite-inhalant form-act in 10 secy Applied subliguallyy Onset of action: 1 to 2 minsy Shelf life: once exposed to air , is short (abt 12

weeks), stored in pill box

Drug of choice : Nitrogylcerine

Alternative drug : Amyl nitrite


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y Therapeutic indicationy Chest pain

y Definitive m/o angina pectorisy Early m/o actue myocardial infarction

y m/o acute hypertesive episodes

y Contraindication:y hypotensive patient

y Sildenafil(viagra) create drug-druginteraction

y Availabilityy Nitroglycerin tablets , 0.15, 0.3,0.4, 0.6 mg

sublingual tablet &y 0.4 , 0.8 mg/ dose nitroglycerin spray.

y 1 bottle of metered translingualnitrogylcerin spray (0.4 mg


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Primary noninjectable: bronchodilator

y 2 adrenergic agonisty Brochial muscle-relaxing properties with

little/no stimulatory action on the CVS & GIT

y Onset of action within 5 min and lastfor 2-4 hrs

y Therapeutic indication:y To treat brochospasm (acute asthmatic

episodes)

y Allergic reactions with brochospasm

Drug of choice : Albuterol(salbutamol)

Alternative drug : Metaproterenol


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Contraindicatied : in patients with preexisting

tachydysrhythmias from prior use of the drug

Dose: 2-4mg oral, 100-200 mue g by

inhalation

Availability:

Albuterol inhalers

Metaproterenol inhalers

Suggested for emergency kit:

1 metered albuterol inahaler


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Primary noninjectable drug-ntihypoglycemics

y Therapeutic indications:y Hypoglycemic states secondary to

DM or fasting hypoglycemia inconscious pt

y Emergency m/o unconscious pt: inabsence parenteral medication

y No side effecty Availability:

y Glucola, insta-gulcose, fruit juices

Drug of choice : orange juice

Alternative drug : soft drink (non diet)


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Primary noninjectable drug -antiplatelet

Action: inhibits TxA2 production &hasantithrombotic effects lasting > 3 days

Therapeutic indication

Patient with suspected myocardialinfarction or unstable angina

Contraindicated

in recent bleeding ulcer and h/o aspirin allergy

Availability: 65, 81, 162, & 325mg tablets

Suggested for emergency kit : 3 or 4 chewableaspirin ( 162mg)

Drug of choice : aspirin


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Oral surgery in patients on anticoagulant

therapy(aspirin)

y Precautiony For uncomplicated forceps extraction of 1 to 3 teeth, there is

usuallyno need to interfere with aspirin treatmenty In patients receiving up to 100mg daily, bleeding during oral

surgical procedures is controllable with suturing and directpackaging. with gauze, resorbable gelatin sponge, oxidizedcellulose, or microfibrillar collagen.

y I

n patients receiving higher doses ofA

spirin, - bleeding time >20 minutes - surgery should be postponed

y ifemergencysurgical treatment is needed :medical advice shouldbe sought to discontinue the use of aspirin intake 7 days beforeoral surgery procedures

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:57-64)


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Emergency equipment

y O2 delivery systemy Positive pressure

y Bag- valve-mask devicey Pocket mask


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Oxygen delivery systemsy Typesy Positive pressure mask

y Bag valve mask device

y

Full face masky Pocket mask

y Suggested for kity One portable cylinder with positive pressure mask

y

One portable self inflating bag-valve-mask devicey Minimum of one child, one small adult and one large

adult full face mask

y One pocket mask


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y Syringes:

y Suction and aspirating apparatus


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Magill intubation forceps

y Blunt ended scissors withright-angle bend

y Aids in placement of

endotracheal tube duringnasal intubation

y Suggested for emergencykity 1 pediatric size


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Tourniquet

y Types

y Rubber or Velcro tourniquet

y

Rubber tubingy Sphygmomanometer


y 3 tourniquet

y 1 Sphygmomanometer


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Automated external defibrilator


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MODULE TWO:

Secondary (Noncritical) Emegency

Drugs And Equipment


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Secondary injectable drug -NTICONVULSANTS

y

Seizure disorder may occur in thedental office under severalcircumstances.

y Including epileptic seizures, overdose

reaction to LA

, obstructive airway inan unconscious patient, and febrileconvulsion,

y Midazolam preferred over diazepambecause its lack of water solubility-limited iv use

Drug of choice : Midazolam

Drug class: Benzodiazepine

Alternative drug : Diazepam


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y Therapeutic indication:y To treat prolonged seizures

y Local anasthetic- induced seizures

y Hyperventilation

y Thyroid storm

y Side effects Respiratory depressionor arrest

y Availbilityy Midazolam : 5mg/ml in (1,2,5, and 10 ml

vial) and 2ml preloaded syringes

y 1mg/ml in (2ml ampules and 10ml vials) andin 2ml preloaded syringes

y Diazepam : 5mg/ml (2ml ampules and 10mlvials) and 2ml preloaded syringes

y Suggested for emergecy kit:y one 5ml vial of midazolam(5mg/ml)


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Secondary injectable drug -analgesic

y

Action of opioid agonisty Therapeutic indication

y Intense, prolonged pain or anxiety,

y acute myocardial infarction and

y

congestive heart failurey Side effects: CNS and RS depressants

y (recent year n2o -o2 are used)

Drug of choice : Morphine sulphet

Drug class: Opioid agonist

Alternative drug : Meperidine


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y Precaution:y Infant and elderly are more susceptible to

respiratory depressant action of morphiney Dangerous in pt with respiratory insufficiency,

sudden death have occurred

y Conraindicated in head injury

y

Availability:y Morphine sulfate 8,10,and 15mg/ml (in 2 ml

ampules and 20 ml vials

y Meperidine : 50 100 mg/ml (in 1ml ampulesand 20 and 30 ml vials

y Suggested for emergecy kit:y 10mg/ml of morphine sulfate two 2ml ampules

y 50mg/ml of meperidine 2ml ampules


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Secondary injectable drug asopressor

y MOA : receptor agonist

y Onset of action:y methaxone

y Imdiate after IV administration and persist for 1 hr

y After IM : 15 min, persist for 90 min

y Phenylephrine:y 5mg IM dose : SBP to elevate 30mmHg, where DBP

20mmHg and response for last 50min

Drug of choice : phenylephrine


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y Therapeutic indication:y To manage hypotension, in which the status of the pts

heart is unknown and the intent is to raise the BP withoutundue cardiac stimulation

y Syncopal reactions

y Drug overdose reactions

y Postseizure states

y Acute adrenal insufficiency

y Allergyy Contraindicate in pt with high BP/ventricular

tachycardia

y Precaution: hyperthyrodism, bardycardia, partialheart block, myocardial disease, or severe

atherosclerosisy Availability:

y Phenylephrine 10mg/ml (1 ml ampules)


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Secondary injectable drug

antihypoglycemic

y Helps in management of low blood

sugar (hypoglycemia)y Therapeutic indication:

y Antihypoglycemics hypogylcemia

y Diagnostic aid in unconsciousness orseizures of unknown origin.

y Side effects: may produce tissue necrosisif extravascular infiltration occurs

Drug of choice : Dextrose, 50% Solution

Alternative drug : Glucagon


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y Glucagon administeretdeither via IV or IM routes

y Availabilityy 50% dextrose in 50ml glass

ampulesy Glucagon : 1mg of dry powder

with 1 ml of diluent and 10mg ofdry powder with 10ml of diluent.

y Suggested for emergency

kit: 50% dextrose (1-2vial),1mg/ml of glucagone

d i j bl d


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y Onset of action: slow

y Therapeutic indicationsy Definitive m/o acute allergy

y Rx of acute adrenal insufficiency

y Availability:y hydrocortisone sodium succinate 50

mg/ml (2ml vial)

y One 2ml vial

Secondary injectable drug corticosteroid

Drug of choice : Hydrocortisone sodium succinate

drug class : adrenal glucocorticosteroid


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y MOA:y 1selective adrenergic (cardio selective) receptor

blocking agent with a very short duration of axn.

y Therapeutic indicationsy Acute hypertensive episodes

y For m/o intra and postoperative tachycardia and

hypertensiony contraindication:

y bradycardia, Heart block, cardiogenic shock

y Availabilityy 10mg/ml in 10ml vial

Secondaryinjectable drug -antihypertensive

Drug of choice : Esmolol

Drug class: 1 adrenergic blocker

Alternative drug : propranolol


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y Therapeutic indicationsy

To treat bradycardia & haemodynamicallysignificant bradydysrhythmias

y Side effects:y over dose can produce hot , dry skin, headache,

blurred vision, dry mouth & throat, hallucination

y Contra indicated in narrow angle

glaucoma:y Availability

y 0.5mg/ml vials- IM

y 1mg/ml in 10ml preloaded syringe-IV

Secondaryinjectable drug parasympathetic blocking agent

Drug of choice : Atropine

Drug class: anticholinergic


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y MOA:y which irritates MM of URT

y Stimulates respiratory andvasomotor centre ofmedulla

y Resp Bpy Movement of hand and leg

y Therapeutic indicationsy Rx respiratory depression

Secondary non-injectable drug respiratory stimulant

Drug of choice : Aromatic ammonia

Drug class: respiratory stimulant


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y Precaution : in COPD/ Asthma- precipitatebrochospasm

y Availability: silver-gray vaporoles containing 0.3ml

of aromatic ammonia.y 1 or 2 boxes of vaporoles,

d d


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y

Therapeutic indication:y Hypertension,

y Acute anginal pain

y Availability:y 10mg and 20mg capsules

y Sug for emer: One bottle of 10mgcapsules

Secondary non-injectable drug antihypertensive

Drug of choice : Nifedipine

Drug class: ca channel blocker

Alternative drug : nitrogylcerine


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Secondary emergency equipments

y Scalpel and cricothyrotomoy needle


y One scalpel with a disposable blade and one

cricothyrotomy device


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Artificial airways


y One set each of adult and

pediatric airway


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Nasopharangel airway


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Laryngeal mask airway (LMA


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Advanced airway devices

y Suggested for emergency kity One laryngoscope and adult and pediatric size

endotracheal tubes


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A

CLS essential drugs(advancedcardiovascular life support)


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y Epinephrin

y Oxygen

y

Lidocainy Atropin

y Dopamin

y Morphin sulfate

yverapamil


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CLS essential:ntidysrhythmic

y Therapeutic indication:y Premature ventricular contraction occur >6

times/min

y sustained ventricular tachycardia with pulse

y Ventricular fibrillation

y S/E:y increase dose - Myocardial, circulatory, and

CNS depression

y More sever overdose- tonic clonic seizure

Drug of choice : lidocaine(xylocaine)

Drug class: LA, antidysrhythmic

Alternative drug : procainamide


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y Avaibility:y 50 or 100 mg (5ml prefilled syringes)

y 100mg- 5ml ampule

y Suggest for emergency kit:y One 100mg preloaded syringe,

y 5ml ampules

ACLS ti l


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y Chemical precursor of epinephriney MOA:

y in large (stimulates both & receptors

y small dose (dilates renal , mesenteric andcerebral arteries,)

y Therapeutic indication:y To treat haemodynamically significant

hypotension in the absence of hypovolemia

ACLS essential:symptomatic hypotension

Drug of choice : dopamine

Drug class: sympathomimetic amine

Alternative drug : dobutamine


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y S/E:y it increase HR induce supraventicuar or

ventcular dysrhytnmias

y Myocardial ishcmiea-

y

Nausea, vomiting

y Avaibility:y 200, 400, and 800mg in 5-ml ampules

y One or two ampules of 400mgdopamine (80mg/ml)

ACLS i l


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y Therapeutic indication:

y Used primarily to treatparoxysmal supraventiculartachycardia,

MAO-slows conduction through theatrioventricular node

ACLS essential:paroxymal supraventicular tachycardia

Drug of choice : Verapamil

Drug class: Ca channel blocker


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y S/E:y transient decrease arterial pressure

y Contraindicated in ventricular tachycardia

y 2.5mg/ml in 2ml and 4ml ampules

y One or two 4ml ampules


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nti dotal drugs

nti dotal drugs


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nti dotal drugs-Opioid antagonist

y MOA:y I

t reverses other properties of opioids, likeanalgesia and sedation

y Therapeutic indication:y Use in opioid induced depression, including

respiratory depression

y S/E:y

Recurrance rs depression may be observed if theopioid previously administerd in longer duration so give second dose IM after IV

y Adult: 0.4mg/ml in 1-ml ampules and 10ml vialsy Pediatric: 0.02mg/ml in 2ml ampules

Drug of choice : NaloxoneDrug class: Thebaine derivative

Alternative drug : Nalbufine

Anti dotal drugs


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y Uses:

y Its reduce the duration of anterogradeamnesia associated with midazolam (frm 121min to 91 min)

y Use to reverse the clinical actions ofparenterally administered benzodizepines

y 0.1mg/ml in 5ml and 10ml multidosevials

y One 10ml multidose vial of f lumazenil

Anti dotal drugs-benzodiazepine antagonist

Drug of choice : flumazenil

Drug class: benzodiazepine antagonist

Anti dotal drugs


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y Emergence delirium:y

Pt appear lose contact with reality, increase muscularmovement and may seem to speak but make onlyunintelligible sound.

y Scopolamine and benzodiazepines most likely producethis phenomenon

y MOA:y reversible anticholinesterase that can cross BBB

y Therapeutic indication:y To reverse the emergence delirium

Anti dotal drugs-

antiemergence delirium

Drug of choice : physostigmine

Drug class: Reversible Anticholinesterase


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y S/E: bradycardia and hypersalivation

y Contra Indication:

yAsthma , DM, CVS Ds,mechanical obstruction of GIT

y 1mg/ml in 2ml ampules

y 2 or 3 ampules


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y uses:y

To manage vasospasm andcompromised circulation followingintra-arterial drug injection

y To manage pain and vascularcompromise following extra vascularadministration of irritating drugs

y 1%(10mg/ml) solution in 2ml and6ml ampules

y 2 ml ampules

Anti dotal drugs-Vasodilator

Drug of choice : procaine

Drug class: local anesthetic


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Other important drugsy Injection Lasix (Frusemide)y Indications

y Renal failure

y Pulmonary edema

y Forced diuresisi in the treatment of barbiturate

poisioning

yAvailabley 10 mg / ml in 2ml ampule

y Dose

y 20mg IV / IM


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y Sodium bicarbonate

y Indications

y

Following cardiac arresty Correction of metabolic acidosis

y Dose

y 1mEq / kg as IV bolus

y Available as 10ml ampule containing 7.5% solution


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y Aminophylline

y Indications

y

Bronchial asthma

y Dosage

y 12.5 mg / min IV (250 mg diluted in 250cc of sterile

water)

y Availability

y 250mg / 2 ml in 10ml vial


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y Calcium gluconate

y Indications

y After massive blood transfusion

y Cardiac arrest

y As a coagulant

y Availability

y 10 ml ampule with 10% w/v (1gm)

y Dosage

y 100-200mg /kg


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Other equipmentsDefibrillators ECG


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Other essentialsy Alcohol sponges

y IV infusion sets

y IV cathetersy Disposable gloves

y Crystalloidsy NS

y DNS

y RL


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Conclusion


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References:-y Essentials of Medical Pharmacology - KD Tripathi

y Pharmacology and Pharmacokinetics - Satoskar

y

Medical Emergencies in the dental office- Stanley f.Malamed

y Principles and practice of medicine- Davidsons

y Principle of contemporary Peterson

y The pharmacological basis of therapeuticsy Goodman and Gillmans


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Documents

Emergency Drugs and Its Uses