Workshop 10 Essential Emergency Drugs - 2024/25 PDF

WORKSHOP 10 Essential Emergency Drugs 3° MEDICINE Academic year: 2024/25 Professor: Vittoria Carrabs PhD  Introduction Emergency medications are used in patients during life- threatening conditions: Manage Saving symptoms...

WORKSHOP 10 Essential Emergency Drugs 3° MEDICINE Academic year: 2024/25 Professor: Vittoria Carrabs PhD  Introduction Emergency medications are used in patients during life- threatening conditions: Manage Saving symptoms patients' lives 2 Introduction  Common medical emergencies that can develop at any time are: ✓ Postural/orthostatic hypotension ✓ Syncope ✓ Asthma attack ✓ Diabetic emergencies (hypoglycemia) ✓ Allergies/hypersensitivity reactions ✓ Chest Pain - Myocardial Infarction ✓ Seizures ✓ Acute adrenal insufficiency ✓ Hyperventilation An emergency kit should ONLY include drugs for which specialist personnel have knowledge and training. 3  BASIC EMERGENCY DRUGS The most commonly used drugs for medical emergencies are: Adrenaline, 1 ml vials of 1:1000 IM solution Aspirin (ASA), 300 mg dispersible tablets Glucagon, 1 mg IM Glycerin Trinitrate Spray, 400 ug Liquid buccal midazolam, 10mg/mL or 5 mg/mL injections (2mL vials) Oral glucose Oxygen Salbutamol (inhaler), 100 ug 4 ADRENALINE/EPINEPHRINE (stimulating activity of α and β adrenergic receptors) Adrenaline is the most important injectable drug in the emergency kit  Endogenous catecholamine  Drug of choice for the treatment of CVD and respiratory manifestations of acute allergic reactions CLINICAL USE: -bronchodilator - Restore proper cardiac output 5 ADRENALINE/EPINEPHRINE (stimulating activity of α and β adrenergic receptors) MOA: α y β adrenoreceptors agonist (SNS) Adrenergic Action receptors α1 Vasoconstriction, increased BP α2 Inhibits the release of NA β1 Tachycardia, myocardial contractility β2 Vasodilation, bronchodilation Adrenaline is most effective when administered after the onset of the reaction in a reanimation dose. 6  ADRENALINE/EPINEPHRINE (Stimulating activity of α and β adrenergic receptors) Indication:Anaphylaxis Adrenaline is indicated when there are signs of stridor, wheezing, respiratory distress or clinical signs of shock 7  ADRENALINE/EPINEPHRINE (stimulating activity of α and β adrenergic receptors) Pharmacokinetics: Parental route→ Rapid onset and short duration of action Metabolism in the liver Urine excretion Crossing the placenta but not the BBB It is distributed in breast milk 8  ADRENALINE/EPINEPHRINE (stimulating activity of α and β adrenergic receptors) In emergency, adrenaline is available in different formulations: Self-injection syringe (EpiPen®; a dose of 0.3 mg = 0.3 mL of Adrenaline 1:1,000 (1 mg/mL; for IM) 1:1,000) Adrenaline 1:10,000 (1 mg/10 ml; for IV) 9  ADRENALINE/EPINEPHRINE (stimulating activity of α and β adrenergic receptors) Indications, dosage and route of administration: Adrenaline 1:1.000→ SEVERE ACUTE ANAPHYLACTIC REACTIONS IM, SC, SL. Preferably managed as IM (faster) Repeat administration of adrenaline every 5 minutes if symptoms such as hypotension, airway inflammation, or bronchospasm persist, carefully monitoring respiratory function, pulse, and blood pressure before each dose.. 10  ADRENALINE/EPINEPHRINE (stimulating activity of α and β adrenergic receptors) Indications, dosage and route of administration: Adrenaline 1:1,000 → SEVERE ACUTE ANAPHYLACTIC REACTIONS Needle too short for larger patients (1.5 cm) Most suitable needles: Babies 1.6 cm, children and 11adults 2.5 cm, large adults 3.8 cm  ADRENALINE/EPINEPHRINE (stimulating activity of α and β adrenergic receptors) Indications, dosage and route of administration: Adrenaline 1:10.000 →Slow intravenous infusion→ CARDIAC ARREST * Patients with profound hypotension or symptoms and signs suggestive of impending shock (dizziness, urinary or stool incontinence) that do NOT respond to initial IM injections of adrenaline Adults: 1 mg [10 mL (1 mg) of 1:10,000 solution] IV (repeat every 3-5 minutes depending on blood pressure, pulse, and respiratory function) Children: 10 μg (0.1 ml of 1:10,000 solution)/kg IV body weight The profound bronchodilator effects →is used for Adrenaline 1:1.000 → the treatment of acute asthmatic attacks that are not relieved by β2-adrenergic receptor agonist sprays. 12  ADRENALINE/EPINEPHRINE (stimulating activity of α and β adrenergic receptors) Drug Interactions:  ↓ Action of insulin  ↑ Hyperthyroidism  Cocaine (sympathomimetic agent):↑ Cardiovascular Effects of Adrenaline  ECV Medications:  α1 antagonists: hypotension and increased heart rate  Non-selective β blockers(Propranolol): Severe hypertension and bradycardia→ Stimulation of adrenergic receptors Cardioselective β1 blockers(atenolol, bisoprolol and metoprolol) do not cause hypertensive reactions after a systemic dose of epinephrine. 13  ADRENALINE/EPINEPHRINE (stimulating activity of α and β adrenergic receptors) Overdose: Symptoms: rapid increase in blood pressure, resulting in cerebrovascular hemorrage cardiac arrhythmias→ Ventricular Fibrillation and Death Treatment: use fast-acting vasodilators (nitrates or α-adrenergic antagonists) Less serious side effects may include: sweating, nausea and vomiting, pale skin, feeling short of breath, dizziness, weakness or shaking, headache, or feeling nervous or anxious. 14  ASPIRINA (NSAID) Recommended in cases of suspected myocardial infarction: Administer to patients presenting with chest pain suggestive of ischemia and evolving myocardial infarction. This intervention helps prevent the progression of cardiac ischemia to infarction and the development of permanent damage. 15  ASPIRINA (NSAID) Mechanism of action ANTIPLATELET -PREVENTS clots from forming PROPERTY! -STOPS the progression of myocardial infarction Dosage and route of administration: 325 mg (dispersible aspirin tablets) Contraindications: ✓ Asthma ✓ Peptic ulcer ✓ Hypersensitivity 16  GLUCAGON Mechanism of action Anti-hypoglycemic action → induces the breakdown of liver glycogen → releases glucose from the liver into the blood Inhibition of gastrointestinal motility: The extra hepatic effects of glucagon include relaxing the smooth muscle of the stomach, duodenum, small intestine, and colon. GlucaGen® Hypokit (1 mg/ml solution) Storage: refrigerator (2 - 8°C) − outside a refrigerator below 25°C for up to 18 months within the shelf life period − Leave it in its original container to protect it from light. Adults: 1 mg IM Children: 0,5 mg IM 17  GLUCAGON Indications: Severe hypoglycemic reactions (low blood sugar) that can occur in patients with DM treated with insulin when oral glucose cannot be administered orally, or if the patient is unconscious. The patient should be given It should be effective in 10 minutes supplemental carbohydrates as soon as The duration of hyperglycemic action after they wake up and are able to swallow IV or IM injection is 60 -90 minutes (especially children or adolescents) If the patient is conscious, oral sugars such as orange juice, cake frosting, or a cola drink work quickly to restore circulating blood sugar. 18  GLUCAGON The American Diabetes Association has recommended the oral administration of a non-diet carbonated beverage. The carbonation in the beverage helps dilate the esophageal and gastric sphincters, allowing the liquid sugar to quickly reach the small intestine, where it is rapidly absorbed to counteract this condition. 19 ORAL GLUCOSE SOLUTION/TABLETS/GEL/POWDER When the patient is cooperative and conscious and with the pharyngeal reflex intact → 10-20 g of rapid-acting glucose should be offered for the treatment of mild to moderate hypoglycemia (it may be necessary to repeat every 10-15 min). With a glucometer, an accurate assessment can be performed within 30 seconds. Blood glucose < 70 mg/dL → 15-20 g glucose should be administered to the patient. 20  GLUCAGON Adequate amounts of glucose must be stored in the liver (as glycogen). Glucagon may be ineffective if the patient: - Has been fasting for an extended period - Has low adrenaline levels - Suffers from chronic hypoglycemia - Has alcohol-induced hypoglycemia - Has a tumor that secretes glucagon or insulin These conditions result in low levels of releasable glucose in the liver 21 and an inadequate reversal of hypoglycemia by GlucaGen treatment  GLUCAGON ADRs: Nausea and vomiting in doses greater than 1 mg or with rapid injection Glucagon (positive inotropic and chronotropic effects) → tachycardia and hypertension. Patients taking β-blockers can be expected to have a greater increase in both pulse and blood pressure (temporary increase →short half-life of glucagon) 22  GLUCAGON Drug interactions:  -blockers  Indomethacin:Glucagon may lose its ability to raise blood glucose or may even cause hypoglycemia.  Warfarin: ↑ Anticoagulant effect  Insulin:Insulin is a glucagon antagonist Use in Pregnancy: Glucagon does not cross the placental barrier 23 NITRATES: GLYCERYL TRINITRATE (GTN)/NITROGLYCERIN Mechanism of action  arterial and venous vasodilation → ↓ Tension of the heart muscle→ ↑ supply of O2 to the heart  treatment of ACUTE SYMPTOMS OF ANGINA or MI  Dosage forms: every 5 minutes Pharmacokinetics: more than 3 sprays It is rapidly absorbed through the buccal and sublingual mucosa → peak plasma concentrations within 4 minutes of SL administration Sublingual Tablets, Tongue Spray 24 NITRATES: GLYCERYL TRINITRATE (GTN)/NITROGLYCERIN Patients with known coronary heart disease should be given clear advice on how to self-medicate with NTG to relieve angina symptoms. An initial dose should be taken at the onset of symptoms. If necessary→ Take two other doses at 5-minute intervals. *If symptoms do not resolve within 5 minutes of administration of the third dose (15 minutes total from symptom onset), emergency medical services should be contacted. If the patient is not allergic to aspirin, administer an aspirin tablet by mouth. 25 NITRATES: GLYCERYL TRINITRATE (GTN)/NITROGLYCERIN ADRs: associated with vasodilation Confirm that the patient has not  Hypotension received a phosphodiesterase  Facial redness inhibitor in the past 24 to 48 hours  Dizziness  Headache  Palpitations Contraindication:Systolic BP below 90 mmHg  Hypotension  Prescription erectile dysfunction medications (sildenafil, tadalafil or vardenafil) → profound hypotension and unconsciousness) 26  MIDAZOLAM Buccolam® → Oromucosal midazolam solution → treatment of prolonged (>5 min) or repeated seizures.  Buccal administration → quickly absorbed into the bloodstream 27  MIDAZOLAM Mechanism of action: benzodiazepines → sedative action. Dosage and route of administration: Adults: a dose of 10 mg (2 ml) buccal Pediatric doses: Child 1–5 years: 5 mg. Child 5–10 years: 7.5 mg. Child above 10 years: 10 mg. ADR: drowsiness and respiratory depression. 28  OXYGEN Indications: for all emergencies, HYPOXEMIA EXCEPT for hyperventilation→ Oxygen may not improve the patient, but it will not worsen their Anaerobic Metabolic condition metabolism acidosis Reduction of efficacy of drugs used for the treatment of medical emergencies 29  OXÍGENO Dose: As needed for the patient 30  SALBUTAMOL INHALER Salbutamol (Ventolin®): − a short-acting β2-adrenergic stimulant Adult dosage:2-3 sprays/1-2 (bronchodilation) min Dosage for children:1 spray /1- − First choice for the treatment of 2 min BRONCHOSPASM ONLY 10% of the drug reaches the airways below; 50% is deposited in the mouth and about 90% is finally ingested Salbutamol inhaler (MDI) 31 SALBUTAMOL INHALER Some patients (children and the elderly) may have difficulty using an inhalation device correctly → The use of a large volume inhalation device may be helpful in these patients ADDITIONAL MEDICATIONS... 33  ANTICHOLINERGIC DRUGS ATROPINE GLYCOPYRROLATE ESCOPOLAMINE 34  1. Atropine (Muscarinic antagonist) Mechanism of action : Antagonizes the M receptors of the Parasympathetic Nervous System Pharmacokinetics: SC, IM, IV crosses the BBB 35 2. Ephedrine (Sympathomimetic, Aginist α/β ) - Similar to epinephrine - Less powerful - Prolonged duration of action 3. Hydrocortisone (Corticosteroid) Anti-inflammatory adrenocortical steroid Use: allergic reactions and adrenal crises (IV: slow onset of action) Epinephrine remains the drug of choice for anaphylaxis and severe allergic reactions (acts immediately). The use of epinephrine should be followed by hydrocortisone administration (IV or IM). 37  ALLERGIC REACTIONS ANTIHISTAMINES Management of allergic reactions → mainly dermatological signs and symptoms such as hives: – MILD non-life-threatening allergic reactions: ORAL administration (25 to 50 mg of diphenhydramine should be taken every 6 hours until symptoms disappear) - Life-threatening reactions: PARENTERAL administration  SYNCOPE AROMATIC AMMONIA A noxious odor that stimulates the respiratory and vasomotor centers of the spinal cord A return to consciousness is usually achieved by placing patients in the Trendelenburg position, administering supplemental oxygen, and using aromatic ammonia. SEVERE PAIN OF THE ACUTE MYOCARDIAL INFARCTION NITROUS OXIDE AMI Pain Relief  SEVERE PAIN OF THE ACUTE MYOCARDIAL INFARCTION MORPHINE 1-3 mg IV or 5 mg IM to pain relief REVERSAL AGENTS NALOXONE To reverse the effects of opioid overdose and respiratory depression. Opioid Receptor Antagonist  REVERSAL AGENTS FLUMAZENIL Benzodiazepine antagonist Reverses BDZ-induced respiratory depression EMERGENCY CLINICAL CASES CLINICAL CASE 1  A 58-year-old male presents to the emergency department with a complaint of sudden, severe chest pain radiating to his left arm. He reports that the pain started 30 minutes ago while he was at rest, and it has progressively worsened. The patient has a history of hypertension, hyperlipidemia, and smoking. He is visibly anxious, sweating, and appears in distress.  Upon initial assessment: Heart rate: 100 beats per minute Blood pressure: 160/90 mmHg Respiratory rate: 18 breaths per minute Oxygen saturation (SpO₂): 95% Physical exam: Diaphoretic, with moderate chest tenderness on palpation, no signs of heart failure (no rales or peripheral edema) Electrocardiogram (ECG) shows ST-segment elevation in leads II, III, and aVF.  Suspected Diagnosis: Acute Myocardial Infarction (ST-Elevation Myocardial Emergency Management, Pain Management And Infarction, STEMI) Monitoring ?  CLINICAL CASE 2 A 30-year-old male is brought to the emergency department unconscious. Paramedics report that the patient was found in his apartment showing clear signs of respiratory depression (shallow, slow, and intermittent breathing) and miosis (extremely constricted pupils). The patient’s history is unclear, but he is known to use fentanyl and other substances. Upon initial assessment: Unconscious, non-responsive to verbal or painful stimuli Heart rate: 50 beats per minute Respiratory rate: 6 breaths per minute (very low) Oxygen saturation (SpO₂): 75% (on room air) Blood pressure: 90/60 mmHg Pupils: Extremely constricted (miosis) No response to painful stimuli (loss of consciousness) Suspected Diagnosis: Fentanyl overdose Emergency Management And Monitoring ?