Technorati Tags: gawat,darurat,obat,drugs,management

Tujuan : Untuk mengembalikan fungsi sirkulasi dan mengatasi keadaan gawat darurat lainnya dengan menggunakan obat-obatan

Perhatian !

Pemberian obat-obatan adalah orang yang kompeten di bidangnya (dokter atau tenaga terlatih di bidang gawat darurat)

Mengingat banyaknya jenis-jenis kegawatdaruratan, maka pemberian obat yang disebutkan di bawah ini untuk mengatasi kegawatdaruratan secara umum sedangkan dalam menghadapi pasien, kita harus melihat kasus per kasus.

Jenis-jenis obat :

Epinephrin

Indikasi : henti jantung (VF, VT tanpa nadi, asistole, PEA) , bradikardi, reaksi atau syok anfilaktik, hipotensi.

Dosis 1 mg iv bolus dapat diulang setiap 3–5 menit, dapat diberikan intratrakeal atau transtrakeal dengan dosis 2–2,5 kali dosis intra vena. Untuk reaksi reaksi atau syok anafilaktik dengan dosis 0,3-0,5 mg sc dapat diulang setiap 15-20 menit. Untuk terapi bradikardi atau hipotensi dapat diberikan epinephrine perinfus dengan dosis 1mg (1 mg = 1 : 1000) dilarutka dalam 500 cc NaCl 0,9 %, dosis dewasa 1 μg/mnt dititrasi sampai menimbulkan reaksi hemodinamik, dosis dapat mencapai 2-10 μg/mnt

Pemberian dimaksud untuk merangsang reseptor α adrenergic dan meningkatkan aliran darah ke otak dan jantung

Lidokain (lignocaine, xylocaine)

Pemberian ini dimaksud untuk mengatasi gangguan irama antara lain VF, VT, Ventrikel Ekstra Sistol yang multipel, multifokal, konsekutif/salvo dan R on T

Dosis 1 – 1,5 mg/kg BB bolus i.v dapat diulang dalam 3 – 5 menit sampai dosis total 3 mg/kg BB dalam 1 jam pertama kemudian dosis drip 2-4 mg/menit sampai 24 jam

dapat diberikan intratrakeal atau transtrakeal dengan dosis 2–2,5 kali dosis intra vena Kontra indikasi : alergi, AV blok derajat 2 dan 3, sinus arrest dan irama idioventrikuler

Sulfas Atropin

Merupakan antikolinergik, bekerja menurunkan tonus vagal dan memperbaiki sistim konduksi AtrioVentrikuler

Indikasi : asistole atau PEA lambat (kelas II B), bradikardi (kelas II A) selain AV blok derajat II tipe 2 atau derajat III (hati-hati pemberian atropine pada bradikardi dengan iskemi atau infark miokard), keracunan organopospat (atropinisasi)

Kontra indikasi : bradikardi dengan irama EKG AV blok derajat II tipe 2 atau derajat III.

Dosis 1 mg IV bolus dapat diulang dalam 3-5 menit sampai dosis total 0,03-0,04 mg/kg BB, untuk bradikardi 0,5 mg IV bolus setiap 3-5 menit maksimal 3 mg.

dapat diberikan intratrakeal atau transtrakeal dengan dosis 2–2,5 kali dosis intra vena diencerkan menjadi 10 cc

Dopamin

Untuk merangsang efek alfa dan beta adrenergic agar kontraktilitas miokard, curah jantung (cardiac output) dan tekanan darah meningkat

Dosis 2-10 μg/kgBB/menit dalam drip infuse. Atau untuk memudahkan 2 ampul dopamine dimasukkan ke 500 cc D5% drip 30 tetes mikro/menit untuk orang dewasa

Magnesium Sulfat

Direkomendasikan untuk pengobatan Torsades de pointes pada ventrikel takikardi, keracunan digitalis.Bisa juga untuk mengatasi preeklamsia

Dosis untuk Torsades de pointes 1-2 gr dilarutkan dengan dektrose 5% diberikan selama 5-60 menit. Drip 0,5-1 gr/jam iv selama 24 jam

Morfin

Sebagai analgetik kuat, dapat digunakan untuk edema paru setelah cardiac arrest. Dosis 2-5 mg dapat diulang 5 – 30 menit

Kortikosteroid

Digunakan untuk perbaikan paru yang disebabkan gangguan inhalasi dan untuk mengurangi edema cerebri

Natrium bikarbonat

Diberikan untuk dugaan hiperkalemia (kelas I), setelah sirkulasi spontan yang timbul pada henti jantung lama (kelas II B), asidosis metabolik karena hipoksia (kelas III) dan overdosis antidepresi trisiklik.

Dosis 1 meq/kg BB bolus dapat diulang dosis setengahnya.

Jangan diberikan rutin pada pasien henti jantung.

Kalsium gluconat/Kalsium klorida

Digunakan untuk perbaikan kontraksi otot jantung, stabilisasi membran sel otot jantung terhadap depolarisasi. Juga digunakan untuk mencegah transfusi masif atau efek transfusi akibat darah donor yang disimpan lama

Diberikan secara pelahan-lahan IV selama 10-20 menit atau dengan menggunakan drip

Dosis 4-8 mg/Kg BB untuk kalsium glukonat dan 2-4 mg/Kg BB untuk Kalsium klorida. Dalam tranfusi, setiap 4 kantong darah yang masuk diberikan 1 ampul Kalsium gluconat

Furosemide

Digunakan untuk mengurangi edema paru dan edema otak Efek samping yang dapat terjadi karena diuresis yang berlebih adalah hipotensi, dehidrasi

dan hipokalemia Dosis 20 – 40 mg intra vena

Diazepam

Digunakan untuk mengatasi kejang-kejang, eklamsia, gaduh gelisah dan tetanus Efek samping dapat menyebabkan depresi pernafasan Dosis dewasa 1 amp (10 mg) intra vena dapat diulangi setiap 15 menit.

 

Dosis pada anak-anak

Epinephrin Dosis 0,01/Kg BB dapat diulang 3-5 menit dengan dosis 0,01 mg/KgBB iv (1:1000)

Atropin Dosis 0,02 mg/KgBB iv (minimal 0,1 mg) dapat diulangi dengan dosis 2 kali maksimal 1mg

Lidokain Dosis 1 mg/KgBB ivNatrium Bikarbonat

Dosis 1 meq/KgBB iv

Kalsium Klorida Dosis 20-25 mg/KgBB iv pelan-pelanKalsium Glukonat

Dosis 60–100 mg/KgBB iv pelan-pelan

Diazepam Dosis 0,3-0,5 mg/Kg BB iv bolusFurosemide Dosis 0,5-1 mg/KgBB iv bolus

Tulisan yang Berhubungan

gawat darurat

Evaluasi Neurologik (Disabity) Aplikasi Resusitasi Jantung Paru (RJP) Resusitasi Jantung Paru (RJP) Terapi Cairan Pengelolaan Sirkulasi (Circulation Management) Terapi Oksigen Keadaan Gawat Darurat yang Mengganggu Pernapasan Pengelolaan Fungsi Pernapasan (Breathing Management)

Pengelolaan Jalan Napas (Airway Management) dengan Alat Pengelolaan Jalan Napas (Airway Management) Tanpa Alat Survei Sekunder (Secondary Survey) Survei Primer (Primary Survey) Triage Penilaian Awal (Initial Assesment) Istilah-istilah Gawat Darurat

Every dentist can expect to be involved in the diagnosis and treatment of medical emergencies during the course of clinical practice. These emergencies may be directly related to dental therapy, or they may simply occur by chance in the dental environment. Although minor medical emergencies occur predictably, a life-threatening emergency may arise as infrequently as once every 10 years. The potential need for acute medical intervention during dental treatment may be increased for those practitioners treating a high percentage of geriatric, special needs, or medically compromised patients, or those using intravenous sedation or general anesthesia.

Emergency Drugs

Even though many medical emergencies may be properly treated without the use of drugs, every dental office must contain an emergency kit with drugs appropriate to the training of the individual dentist, the patient being treated, and the type of procedures being performed. Obviously, no drug can take the place of a properly trained health professional and support staff in diagnosing and treating emergencies. Nevertheless, the design and/or purchase of an appropriate emergency kit will often play an integral role in dictating the course and outcome of emergency treatment.

Besides determining which drugs should be included in an emergency kit, the dentist must understand that it will be necessary to maintain the knowledge base to use them. In the midst of a medical emergency, with the patient by definition in an acutely abnormal or even critical situation, there is no time to begin reading labels, leafing through emergency texts, or administering drugs as suggested by a brochure in the emergency kit. In addition, there is a significant difference between the theoretical knowledge of how to treat an emergency and being able to put such cognitive skills to practical use. Only constant review and training will keep the dental team sharp. Regular continuing education in medical emergencies and review of pharmacology, certification, and recertification in basic life support (BLS), and in some offices advance cardiac life support (ACLS), coupled with emergency drills are the best methods to prepare for emergencies. Without prompt attention to the ABCs (airway, breathing, circulation) of cardiopulmonary resuscitation, drugs are of little value.

The role of drugs and how much intervention, should be attempted by a dentist during a medical emergency is a controversial issue. If any consequence of dental treatment is

foreseeable and results in harm, liability may be imposed . Emergency drugs are generally powerful, rapidly acting compounds. The correct

approach to the use of drugs in any medical emergency should be essentially supportive and conservative. In a review covering the use over a 2-year period of 8500 emergency drug systems purchased by dentists, a 0.75% incidence was reported.

Emergency kits can be either organized by the individual practitioner or purchased commercially. Many dentists are not comfortable deciding and purchasing individual drugs for their emergency kits, and the purchase of high-quality, commercially available emergency drugs kit modified for one's particular needs can provide consistent drug availability (i.e., periodic drug updating).

There is a general tendency to overequip basic dental emergency kits with drugs that are beyond the needs and expertise of many general dentists. As a rule, the drugs placed in an office emergency kits should only include those drugs familiar to the dentist. It is also best to include only one agent for a particular need. The fewer drugs in an emergency kit, the easier it is to know their proper use, especially during an emergency.

Mandatory Emergency Drugs

There are certain drugs that all dentists must keep readily available in the office in fresh supply for immediate administration (See Table 1 below). Dentists must know reflexively when, how, and in what doses to give these specific agents for acutely life-threatening situations.

Oxygen is a primary, if not the primary, emergency drug indicated in any medical emergency where hypoxemia may be present. These emergencies include, but are not limited to, acute disturbances involving the cardiovascular, respiratory, and central nervous systems. In the hypoxemic patient, breathing enriched oxygen elevates the arterial oxygen tension, which in turn improves oxygenation of

peripheral tissues. Because of the steepness of the oxyhemoglobin dissociation curve, a modest increase in oxygen tension can significantly alter hemoglobin saturation in the hypoxemic individual. Hypoxemia leads to anaerobic metabolism and metabolic acidosis, which often adversely affects the efficacy of emergency pharmacologic interventions.

Table 1: Mandatory Emergency Drugs

Drugs Indications Preparations

OxygenFor use in all medical emergencies where  hypoxemia may be present

Steel cylinders (green); E tanks, 690 L

Epinephrine Acute allergic reactions Ampules: 1 mg

Acute asthma (not responding to adrenergic inhaler)

Vials: 1 and 30 mg Syringes: 0.3 and 1 mg

NitroglycerinAngina pectoris Acute myocardial infarction

Tablets (sublingual): 0.15, 0.3, 0.4, and 0.6 mg Spray: 0.4 mg/actuation

Adapted from:

Holroyd SV, Wynn RL, Requa-Clark, B: Clinical pharmacology in dental practice, ed 4, St. Louis, 1988, The C. V. Mosby Company

Oxygen can be delivered to the spontaneously breathing patient via full face mask, nasal cannulae, or nasal hood. Dental offices should also have the capacity to deliver oxygen via positive-pressure ventilation. Controlled ventilation may be accomplished with the use of a bag-valve-mask device (consisting of a mask, self-inflating bag, and nonrebreathing valve) or with a manually triggered oxygen-powered breathing device (consisting of a mask connected via a valve activated by a lever and high-pressure tubing to the oxygen supply). Each method of providing positive-pressure ventilation requires some practice for effective use. It is difficult with the bag-valve mask device to provide a seal around the nose and mouth while simultaneously ventilating the patient. The oxygen-powered device is easier to use but care must be taken not to inflate the stomach.

Both techniques, however, are preferred over mouth-to-mouth, mouth-to-nose, or mouth-to-mask techniques. Airway adjuncts, such as oropharyngeal and nasopharyngeal airways, endotracheal equipment, laryngeal masks, and the means of establishing an emergency airway via cricothyrotomy and transtracheal ventilation can be useful or even life-saving in the hands of a trained and experienced health professional. Without appropriate training, however, their use may prove deleterious in an acute emergency.

There are absolutely no contraindications to the administration of oxygen in emergency situations. Although oxygen toxicity may occur after prolonged therapy with high concentrations of oxygen, it is not an issue during clinical resuscitation. This statement holds true even for the rare patient whose respiratory drive is dependent on hypoxemia because of chronically elevated carbon dioxide concentrations. If clinically indicated, oxygen should never be withheld during any medical emergency.

Epinephrine The inclusion of epinephrine in a dental office emergency kit is mandatory for the treatment of cardiac arrest and overwhelming anaphylaxis. However, it must be emphasized that these extreme conditions are the only situations that would require its use in the dental office emergency. There are a few clinicians who maintain the mistaken belief that epinephrine is the drug of choice in shock or shocklike states. There are three principal reasons for disputing this belief.

First, in shock from almost any cause there is decreased venous return to the heart because of peripheral venous pooling. Because the peripheral action of epinephrine is primarily on the arterial side, there is little gain in promoting peripheral vasoconstrictions, which is already present because of the massive release of endogenous catecholamines (epinephrine and norepinephrine). At this point administration of epinephrine may further decrease venous return and tissue perfusion. Second, a possible deleterious effect is an increase in selective ischemia that takes place in certain viscera such as the kidney. Here, as in peripheral vessels, the blood supply is constricted in a compensatory effort to increase blood flow to the more vital brain and heart tissues. Perpetuation of this condition could be undesirable. Third, the possible precipitation of ventricular fibrillation in the ischemic and irritable myocardium is an important factor. This could be especially disastrous in the dental office where defibrillation equipment is usually not available. In early treatment of shock states the patient will benefit more from measures aimed at correction of the primary cause such as hypovolemia rather than misdirected attempts at pharmacologic correction.

Desirable properties of this agent include a rapid onset of action; potent action as a bronchial smooth muscle dilator (beta2

properties); antihistaminic actions; vasopressor actions; and its actions on the heart, which include an increased heart rate (21%), increased systolic blood pressure (5%), decreased diastolic blood pressure (14%), increased cardiac output (51%), and increased coronary blood flow. Undesirable actions include its tendency to predispose the heart to dysrhythmias and its relatively short duration of action.

Epinephrine is an important drug during cardiac arrest because no other drug is capable of maintaining coronary artery blood flow while CPR is in progress, which is essential for preserving the chances of survival from cardiac arrest. Epinephrine also preserves blood flow to the brain. In the absence of drug therapy, cerebral blood flow during CPR is minimal; most blood enters the common carotid artery and flows into the external carotid branch, not the internal carotid artery. Following administration of a drug with a-adrenergic properties, such as epinephrine, cerebral blood flow is significantly increased.

For the effective treatment of acute allergic reactions, epinephrine must be administered as soon as the condition is diagnosed. The drug can be injected subcutaneously 0.3 to 0.5 mL of a 1:1000 solution, or intramuscularly (for a more serious emergency), 0.4 to 0.6 mL of the same solution. The intravenous route is also possible, but it may induce or exacerbate ventricular ectopy, especially in patient receiving digitalis. Epinephrine may also be instilled directly into the tracheobronchial tree via an endotracheal tube with good results.

Because of its profound bronchodilating effects, epinephrine is also indicated for the treatment of acute asthmatic attacks unrelieved by b2-adrenergic sprays or aerosols.

Side effects, contraindications, and precautions: Tachydysrhythmias, both supraventricular and ventricular, may develop. Epinephrine should be used with caution

in pregnant women because it decreases placental blood flow and may induce premature labor. When used, all vital signs must be monitored frequently. In the setting of the dental practice, epinephrine will usually be considered for administration in situations that are considered to be life threatening (anaphylaxis, cardiac arrest). Under such situations the advantages of administering this agent clearly outweigh any risk. In effect there are no contraindications to the administration of epinephrine under these conditions.

Antihistamines will be of value in the treatment of the delayed allergic response and in the definitive management of the acute allergic reaction (administered after epinephrine has terminated the acute life-threatening phase of the reaction). Antihistamines act as competitive antagonists of histamine. They do not prevent the release of histamine from cells in response to injury, drugs, or antigens, but do prevent access of histamine to its receptor site in the cell and thereby block the response of the effector cell to histamine. Thus, antihistamines are more potent in preventing the actions of histamine than in reversing these actions once they develop.

Nitroglycerin Vasodilators are used in the immediate management of chest pain (such as may occur with angina pectoris or acute myocardial infarction). Two varieties of vasodilator are available: nitroglycerin (TNG) as a tablet and a spray, and an inhalant, amyl nitrite. A patient with a history of angina pectoris will usually carry a supply of nitroglycerin. Tablets remain the most popular form of TNG, although most patients prefer the translingual spray once they have used it.

During dental care a patient's nitroglycerin source should be readily accessible. Placed sublingually or sprayed onto the lingual soft tissues, nitroglycerin acts in 1 to 2 minutes. A patient's drug should be used if at all possible, but if it is not available or is ineffective, the 0.4-mg dosage form should be available in the emergency kit. The shelf life of TNG tablets once exposed to air is quite short (about 6 weeks). This is especially true when the container is not adequately sealed or the tablets are stored in a pill box. In these cases the active nitroglycerin vaporizes, leaving behind an inert filler. This is not normally a problem with patients most of whom will use a bottle of tablets in 4 to 6 weeks. Inactivation of the TNG is more likely to occur in the dental office supply where its use is extremely sporadic. Nitroglycerin tablets placed sublingually usually taste bitter and sting. Suspect that the drug has become ineffective if the bitter taste is absent.

Amyl nitrite, another vasodilator, is available for use as an inhalant. It is supplied in a yellow vaporole or a gray cardboard vaporole with yellow printing in a dose of 0.3 mL, which when crushed between one's finger and held under the victim's nose will act in about 10 seconds to produce a profound vasodilation. The duration of action of amyl nitrite is shorter than that of TNG; however, the shelf life of the vaporole is considerably longer. Side effects occur with all vasodilators but they are more significant with amyl nitrite.

Side effects, contraindications, and precautions: Side effects of nitroglycerin include a transient pulsating headache, facial flushing, and a degree of hypotension (noted

especially if the patient is in an upright position). Because of its mild hypotensive actions, nitroglycerin is contraindicated in patients who are hypotensive, but may be used with some degree of effectiveness in the management of acute hypertensive episodes. Side effects of amyl nitrite are similar to but more intense than those of nitroglycerin. These include facial flushing, pounding pulse, dizziness, intense headache, and hypotension. Amyl nitrite should not be administered to patients who are in an upright position because the patient may feel dizzy and suffer a fall.

Primary Support Drugs

Primary support drugs are helpful for treating medical emergencies that are usually not acutely life-threatening. Although it is not mandatory that every dentist include these drugs in the emergency kit, they are all useful, particularly in situations where the dentist is familiar with their use and where emergency medical services may not be immediately available.

Secondary Injectable Drugs: Seven drug categories are included in this level:

1. Anticonvulsant

2. Analgesic

3. Vasopressor

4. Antihypoglycemic

5. Corticosteroid

6. Antihypertensive

7. Anticholinergic

Noninjectable drugs: There are three noninjectable drugs that are considered at this level:

1. Respiratory stimulant

2. Antihypoglycemic

3. Bronchodilator

Table 2: Emergency Support Drugs

Category Generic Proprietary Alternative

       

Injectables

Anticonvulsant Midazolam Versed Diazepam

Analgesic   Morphine   Meperidine

Vasopressor Methoxamine Vasoxyl Phenylephrine

Antihypoglycemic 50% Dextrose sol.   Glucagon

Corticosteroid   Hydrocortisone Solu-Cortef sodium succinate

  Dexamethasone

Antihypertensive  Labetalol HCl   Normodyne

Anticholinergic Atropine    

 

Noninjectables     

Respiratory stimulant Aromatic Ammonia    

AntihypoglycemicCarbohydrate            Decorative icing

Many  

Bronchodilator Albuterol Ventolin, Proventil Metaproterenol

Antihypertensive Nifedipine Procardia  

Adapted from: Malamed SF: Sedation: a guide to patient management, ed 2, St. Louis, 1991, Mosby-Year Book.

Anticonvulsant Seizures that may require acute medical intervention may be associated with epilepsy, hyperventilation episodes, cerebrovascular accidents, hypoglycemic reactions, or vasodepressor syncope. Local anesthetic overdoses or accidental intravascular injection may also require the administration of an anticonvulsant. Current management of a seizure that interferes with ventilation or persists for longer than 5 minutes includes the use of an intravenous benzodiazepine such as diazepam or midazolam.

With its introduction, diazepam became the preferred anticonvulsant. Because seizure disorders are characterized by a stimulation of the central nervous and cardiorespiratory and cardiovascular systems, followed by a period of depression of these same systems, drugs that depress the systems at therapeutic does are more likely to produce postseizure complications. When barbiturates are administered to terminate seizure activity, the degree of postseizure depression is accentuated and its duration prolonged because of the pharmcologic action of the barbiturate.

If the doctor is not adapt at recognizing and managing this situation, the patient may be worse off after the seizure than during it. The benzodiazepines, unlike barbiturates, will usually terminate seizure activity without the pronounced depression of the respiratory and cardiovascular systems.

Analgesic medications will be useful during emergency situations in which acute pain or anxiety is present. In most instances the presence of pain or anxiety will cause an increase in the workload of the heart (and an increased myocardial oxygen requirement) that may prove detrimental to the well-being of the patient. Two such circumstances are acute myocardial infarction and congestive heart failure. The choice of analgesic drugs includes the narcotic agonists morphine sulfate and meperidine (Demerol).

Side effects, contraindications, and precautions: Narcotic agonists are potent CNS and respiratory depressants. Vigilant monitoring of vital signs is mandatory whenever these agents are used. Use of narcotic agonists is contraindicated in victims of head injury and multiple trauma; they should be used with care in persons with compromised respiratory function.

Vasopressor In most emergency situations in which a vasopressor is indicated in the dental office, an agent such as epinephrine will not be the drug of choice. Epinephrine will be used primarily in the management of acute allergic reactions and is rarely employed in cases of clinically mild to moderate hypotension. One reason for this is that epinephrine elicits an extreme antihypotensive response. In addition to an increase in blood pressure, epinephrine causes an increase in the workload of the heart through its effect on heart rate and cardiac contraction; it also increases the irritability of the myocardium by sensitizing it to dysrhythmias.

Vasopressors such as methoxamine (Vasoxyl) and phenylephrine (Neo-Synephrine) are drugs that produce moderate blood pressure elevations through peripheral vasoconstriction.

Methoxamine is a clinically useful vasopressor with sustained action and little effect on the myocardium or central nervous system. Its vasopressor action is associated with a marked increase in peripheral resistance and no increase in cardiac output. A compensatory bradycardia accompanies the rise in blood pressure produced by methoxamine. The onset of the pressor action is almost immediate following IV administration and may persist for up to 60 minutes. After IM injection the response occurs within 15 minutes and persists for 90 minutes.

Phenylephrine acts in a similar fashion, with a 5-mg IM dose causing a 30-mm Hg elevation of systolic blood pressure and a 20-mm Hg elevation of diastolic blood pressure, with the response persisting for 50 minutes. As with methoxamine, a pronounced and persistent bradycardia will be noted (average decline in heart rate from 70 to 44 beats per minute).

Antihypoglycemic Glucose preparations are used to treat hypoglycemia that results either from fasting or insulin use in a patient with diabetes mellitus. If the patient is conscious, oral carbohydrates such as chocolate bar, cake icing, or cola drink will act rapidly to restore circulating blood sugar. On the other hand, if the patient is unconscious and acute hypoglycemia is suspected, intravenous administration of 50% dextrose solution is the treatment of choice.

Corticosteroids will be administered in the management of an acute allergic reaction, but only after the acute phase has been brought under control through the use of basic life support, epinephrine, and antihistamines. The primary value of the corticosteroids is in the prevention of recurrent episodes of anaphylaxis. Corticosteroids are also important in the management of acute adrenal insufficiency.

The onset of intravenous corticosteroids, such as hydrocortisone sodium succinate, is delayed, but the drugs can be useful in halting the progression of a major allergic or anaphylactoid reaction. There is also the potential for encountering what appears initially to be a syncopal episode but is in reality the more serious problem of acute adrenal insufficiency in a patient chronically taking systemic corticosteroids to treat a medical condition. For this life-threatening emergency, only the prompt diagnosis and infusion of corticosteroids will be curative.

Hydrocortisone sodium succinate is considered the drug of choice for the dental emergency kit. Corticosteroids are considered second-line drugs primarily because of their slow onset of action.

Antihypertensive The need to administer drugs to decrease excessive elevations in blood pressure is extremely uncommon. First, the incidence of extreme acute blood pressure elevation is quite rare and, second, there are other means of decreasing blood pressure without resorting to parenteral antihypertensive drugs.

Emergency Drugs Oral drugs, such as nifedipine or nitroglycerin, may be administered in most situations to provide a minor depression of blood pressure. The inclusion of a drug in this category is in response to state requirements for general anesthesia permits (and in a few states for parenteral sedation, too).

Anticholinergic Atropine, a parasympathetic blocking agent, is recommended for the management of symptomatic bradycardia (adult heart rate of <60 beats per minute). By enhancing discharge from the sinoatrial (SA) node, atropine may provoke tachycardia (adult heart rate>100 beats per minute). Atropine will be of benefit in situations in which the patient has an overload of parasympathetic activity on the heart. Extremely fearful patients are likely candidates for this response.

Atropine is also considered an essential drug in advanced cardiac life support (ACLS), in which it is employed in the management of bradydysrhythmias (hemodynamically significant heart block and asystole).

Side effects, contraindications, and precautions: Large doses of atropine (>2.0 mg) may produce clinical signs of overdosage, including: hot, dry skin; headache; blurred near vision; dryness of the mouth and throat; disorientation; and hallucination. Administration of atropine is contraindicated in patients with glaucoma or prostatic hypertrophy. However, in life-threatening situations the benefits of atropine administration usually outweigh the possible risks.

Respiratory stimulant After oxygen, aromatic ammonia is the most commonly used drug in the emergency situation. It is available in a silver-gray vaporole, which is crushed and placed under the victim's nose until respiratory stimulation is effected. Aromatic ammonia has a noxious odor and acts by irritating the mucous membrane of the upper respiratory tract, thereby stimulating the respiratory and vasomotor centers of the medulla; this in turn increases respiration and blood pressure. Movement of the arms and legs often occurs in response to inhalation of ammonia. This too acts to increase the return of blood from the periphery and aids in raising blood pressure, especially if the patient has been positioned properly.

Side effects, contraindications, and precautions: Ammonia should be employed with caution in persons with chronic obstructive pulmonary disease (COPD) or asthma because its irritating effects on the mucous membranes of the upper respiratory tract may precipitate bronchospasm.

Antihypoglycemic agents will be useful in the management of hypoglycemic reactions occurring in patients with diabetes mellitus or in the nondiabetic patient with hypoglycemia (low blood sugar). The diabetic patient will usually carry a ready source of carbohydrate such as a candy bar or hard candy. Such items should also be available in the dental office for use in the conscious patient with hypoglycemia.

Bronchodilator Asthmatic patients and patients with allergic reactions manifested primarily by respiratory difficulty will require the use of bronchodilator drugs. Although epinephrine remains the drug of choice in the management of bronchospasm, its wide ranging actions on systems other than the respiratory tract has resulted in the introduction of newer, more specific agents known as b2-adrenergic agonists. These agents, of which albuterol is an example, have specific bronchial smooth muscle-relaxing properties (b2) with little or no stimulatory effect on the cardiovascular and gastrointestinal systems (b1) . In the dental situation in which the patient's true cardiovascular status may be unknown, b2 agonists appear more attractive for management of the acute asthmatic episode than agents that have both b1 and b2

agonist properties, such as epinephrine and isoproterenol.

Bronchodilators must be administered precisely as directed. One to two inhalations every 4 to 6 hours is the recommended dosage for albuterol. Nebulized epinephrine (e.g., Primatene-Mist â ) should be administered one to two inhalations per hour. In situations in which these nebulized agents fail to terminate the attack, other bronchodilators (e.g., epinephrine, aminophylline, isoproterenol) must be administered parenterally (intramuscularly or subcutaneously).

Side effects, contraindications, and precautions: Albuterol, like other b2 agonists, may have a clinically significant cardiac effect in some patients. This response is less likely to develop with albuterol than with other bronchodilators, thus its selection for the emergency kit. Metaproterenol, epinephrine, and isoproterenol mistometers are more likely to produce cardiovascular side effects, including tachycardia and ventricular dysrhythmias.

Drugs For Advanced Cardiac Life Support

ACLS is the standard of care for comprehensive resuscitation by health care providers with advanced skills and training. Training in ACLS is necessary for those dentists administering deep sedation or general anesthesia and is sometimes required by state law for providers of parenteral conscious sedation. State regulations should be consulted to determine which of the drugs described here must be available when sedation or anesthesia is administered.

Table 3: Advanced Cardiac Life Support Drugs

Drug Indication

 

Antiarrhythmics 

LidocaineVentricular tachycardia, pulseless, ventricular tachycardia, or ventricular fibrillation

ProcainamideVentricular tachycardia, pulseless ventricular tachycardia or ventricular fibrillation

BretyliumVentricular tachycardia, pulseless ventricular tachycardia or ventricular fibrillation

Verapamil, diltiazemAtrial flutter or atrial fibrillation, paroxysmal supraventricular tachycardia

Adenosine Paroxysmal supraventricular tachycardia

AtropineBradycardia, asystole, first-degree and Mobitz type I atrioventricular block, Mobitz type II and third-degree block

Magnesium Torsades de pointes, ventricular fibrillation

ß blockers (e.g., propranolol)Atrial flutter or atrial fibrillation, refractory ventricular tachycardia or ventricular fibrillation

 

Inotropes 

EpinephrineVentricular fibrillation, asystole, pulseless, electrical activity, bradycardia

Norepinephrine Refractory hypotension

Dopamine Bradycardia, hypotension

Dobutamine Congestive heart failure

Isoproterenol Refractory bradycardia

Digitalis Atrial flutter, fibrillation

Amrinone Refractory congestive heart failure

 

Vasodilators/Antihypertensives 

Nitroprusside Hypertension, acute heart failure

NitroglycerinHypertension, acte heart failure, anginal pain

 

Others 

Sodium bicarbonateHyperkalemia, metabolic acidosis with bicarbonate loss, hypoxic lactic acidosis

Furosemide Acute pulmonary edema

Morphine Acute pulmonary edema, pain and anxiety

Thrombolytic agents (e.g., anistreplase) Acute myocardial thrombosis

Adapted From: Holroyd SV, Wynn RL, Requa-Clark, B: Clinical pharmacology in dental practice, ed 4, St. Louis, 1988, The C. V. Mosby Company

Supplementary Drugs

Supplementary drugs are additional emergency drugs that must be available when certain sedative or anesthetic drugs are administered. They include drugs that are used to reverse untoward effects of anesthetics and others that are used to treat specific medical conditions that may occur during anesthesia.

Categories of antidotal drugs include:

1. Narcotic antagonist

2. Benzodiazepine antagonist

3. Antiemergence delirium drug

4. Vasodilator

 

Table 4: Antidotal Drugs

Category Generic Proprietary Alternative

Narcotic antagonist Naloxone Narcan Nalbuphine

Benzodiazepine Flumazenil Mazicon  

antagonist

Antiemergence delirium

Physostigmine Antilirium  

Vasodilator Procaine Novocain  

Adapted From: Malamed SF: Sedation: a guide to patient management, ed 2, St. Louis, 1991, Mosby-Year Book.

Narcotic antagonist Naloxone is a specific opioid antagonist that reverses opioid-induced respirator depression. It is mandatory in practices where parenteral opioids are administered. Naloxone will also reverse other properties of narcotics, namely analgesia, and sedation. This action is not entirely innocuous because if narcotics have been employed for postsurgical analgesia naloxone administration will antagonize this effect and leave the patient with unmanaged postsurgical pain.

Side effects, contraindications, and precautions: When administered intravenously or endotracheally, the duration of naloxone is but 30 minutes. A recurrence of respiratory depression may be observed if the narcotic employed is of longer duration (e.g., morphine). It is common for a second dose of naloxone to be administered intramuscularly following the intravenous dose. Though slower in onset, the duration of therapeutic action of IM naloxone is considerably longer than IV administration. This regimen will minimize the possibility of a recurrence of respiratory depression.

Benzodiazepine antagonist Although the benzodiazepines have been described as the most nearly ideal agents for anxiety control and sedation, there are still a number of adverse reactions associated with their administration. Emergence delirium, excessive duration of sedation, and possible (though unlikely in most instances) respiratory depression are but a few side effects. The availability of a specific antagonistic agent for benzodiazepines adds another degree of safety to intravenous and, to a lesser extent, intramuscular sedation. Flumazenil has been demonstrated to produce a rapid reversal of sedation and improve a patient's ability to comprehend and obey commands.

Flumazenil is recommended whenever benzodiazepines such as diazepam, midazolam, or lorazepam are administered parenterally.

Antiemergence delirium Several drugs that are commonly employed parenterally to induce sedation have the ability to produce what is known as emergence delirium. Scopolamine and the benzodiazepines, diazepam and midazolam, are most likely to produce this phenomenon in which the patient appears to lose contact with reality. Physostigmine (Antilirium), a reversible cholinesterase with the ability to cross the blood-brain barrier, has become the drug of choice in the management of emergence delirium.

Vasodilator A local anesthetic that also possesses significant vasodilating properties is recommended for inclusion in the emergency kit whenever IM or IV drugs are employed. Indications for the use of this drug are extravascular injection of an irritating

chemical and accidental intraarterial administration of a drug. In both instances the problem is that of compromised circulation in either a localized area (extravascular administration) or a limb (intraarterial administration).

Procaine possesses excellent vasodilating properties along with its pain-relieving actions, both of which make this drug ideal for administration in the aforementioned situations.

Sources:

Holroyd SV, Wynn RL, Requa-Clark, B: Clinical pharmacology in dental practice, ed 4, St. Louis, 1988, The C. V. Mosby Company

Malamed SF: Sedation: a guide to patient management, ed 2, St. Louis, 1991, Mosby-Year Book.

 

Table 5: Emergency Drug Kit

Drug IndicationsAdult Dosage and Route of Administration

Epinephrine (Adrenalin)-1:1000

anaphylaxis, cardiac arrest 0.5 ml intravenously

Methylprednisolone sodium succinate (Solu-Medrol)-125 mg Monovile

cardiac arrest, anaphylaxis, acute adrenocortical insufficiency

125 mg intravenously, given slowly

Sodium bicarbonate–7.5% cardiac arrest1 mEq/kg intravenously initially, then half this every 10 minutes

Diphenhydramine (Benadryl) 10 mg/ml

acute allergic reaction, extrapyramidal reaction to phenothiazine

5 ml intravenously

Aromatic spirits of ammonia- crush ampules

syncope one ampule, by inhalation

Glyceryl trinitrate–0.6 mg tablet

angina pectoris one tablet sublingually

Morphine sulfate–15mg/ml myocardial infarction1 ml subcutaneously or intravenously

Phenylephrine hydrochloride (Neo-Synephrine Hydrochloride) – 1:500

toxic reaction to local anesthetic

1 to 2 ml intravenously

Dextrose in water–5%hypovolemia, IV route for drug administration

1000 ml IV drip

Diazepam– 5 mg/mlsevere or prolonged convulsion as in toxic reaction to local anesthetic

1 to 8 ml intravenously (titrated)

Naloxone hydrochloride(Narcan)       –0.4 mg/ml

narcotic depression1 ml intravenously or intramuscularly

Isoproterenol hydrochloride aerosol–0.25%

bronchospasm one or two inhalations

Physostigmine salicylate – 1mg/ml

CNS depression following diazepam administration

0.5 to 2 ml intravenously (slow titration)

Atropine sulphate–0.1 mg/ml

bradycardia with hypotension

0.5 - 1.0 mg IV

Adapted From: Holroyd SV, Wynn RL, Requa-Clark, B: Clinical pharmacology in dental practice, ed 4, St. Louis, 1988, The C. V. Mosby Company

 

References

1. American Heart Association and National Academy of Sciences: National Research Council: Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECG), JAMA 255:2905, 1986.

2. American Heart Association: Textbook of advanced cardiac life support, Dallas, 1987, American Heart Association.

3. Barsan WG, Jastremski MS, Syverud SA, eds: Emergency drug therapy, Philadelphia, 1991, WB Saunders.

4. Council on Dental Therapeutics: Emergency kits. J Am Dent Assoc 87:909, 1973.

5. Curriculum guidelines for management of medical emergencies in dental education, J Dent Educ 54:337-338, 1990.

6. Davenport HT: Anesthesia in the elderly, New York, 1986, Elsevier Science.

7. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees. American Heart Association. Adult advanced cardiac life support, JAMA 268:2199-2241, 1992.

8. Guidelines for teaching the comprehensive control of pain and anxiety in dental education, Chicago, 1989, American Dental Association.

9. Hasegawa EA: The endotracheal use of emergency drugs, Heart Lung 15:60-63, 1986.

10.Healthfirst Corporation: Emergency medicine videotape, Seattle, 1991.

11. Lipp M, et al: Management of an emergency: to be prepared for the unwanted event, Anesth Pain Control Dent 2:90-102, 1992.

12. Malamed SF: Sedation: a guide to patient management, ed 2, St. Louis, 1991, Mosby-Year Book.

13. McCarthy FM, ed: Medical emergencies in dentistry, Philadelphia, 1982, WB Saunders.

14. Miller CS, et al: Documenting medication use in adult dental patients: 1987-1991, J Am Dent Assoc 123: 40-48, 1992.

15. Moore PA: Review of medical emergencies in dentistry: staff training and prevention. Part 1. Gen Dent 36:14-17, 1988.

Emergency Drugs16. Munson ES, Wagman IH: Diazepam treatment of local anesthetic-induced seizures, Anesthesiology 37:523-528-1972.

17. Morrow GT: Designing a drug kit, Dent Clin North Amer 26 (1): 21-33, 1982.

18. Newhouse MT, Dolovich MB: Control of asthma by aerosols, N Engl J Med 315:870-874, 1986.

19. Otto CS, Yakaitis RW: The role of epinephrine in CPR: a reappraisal, Ann Emerg Med 13:840-843, 1984.

20. Paradis NA, Koscove EM: Epinephrine in cardiac arrest: a critical review, Ann Emerg Med 19:1288-1301, 1990.

21. Patterson NA, Koscove EM: Allergic reactions to drugs and biologic agents, JAMA 248:2637-2645, 1982.

22. Phero JC: Maintaining preparedness for the life-threatening office medical emergency, Dent Econ 81:47-50, 1991.

http://www.homesteadschools.com/dental/courses/Emergency%20Drugs/text.htm

clinical practiceAndrew BairdMA, MBChB, DRANZCOG, DA, FRACGP, FACRRM,is a general practitioner, Brighton, Victoria.bairdak@gmail.com

Emergency drugs in general practiceGeneral practitioners need the knowledge, skills, drugs andequipment for managing medical emergencies. Clinics needtreatment rooms and doctor’s bags that enable emergencies to bemanaged onsite and offsite respectively. Rural medical generalistsmay provide more advanced emergency management in their localhospitals. In managing emergencies, GPs may be working withparamedics, therefore it helps to be familiar with their skills andwith the drugs they carry. General principles that apply inmanaging medical emergencies are described in Table 1. Relevantcontraindications should be checked before administering any ofthe drugs described below (Table 2).

Life threatening medical emergenciesCardiac arrestCurrent guidelines1 emphasise the importance of cardiac compressions, andprompt defibrillation for ventricular fibrillation (VF) or pulseless ventriculartachycardia (VT). Adrenaline is given every 3 minutes intravenously (IV) untilreturn of spontaneous circulation (ROSC):• adult dosage: 1 mg with a saline flush (10–20 mL)• paediatric dosage: 0.01 mg/kg (10 μg/kg) (Table 3) with a saline flush (upto 5 mL).During cardiopulmonary resuscitation, the following drugs may beconsidered:• VF or VT: lignocaine 1 mg/kg• asystole or severe bradycardia: atropine 1.2–3.0 mg (adult);20 μg/kg (child)In the hospital setting amiodarone is the first line drug for treatingventricular arrhythmias. Following ROSC, blood pressure (BP) and adequateperfusion should be maintained. This may require IV adrenaline (Table 4).Anaphylaxis2

• Adrenaline is given every 5 minutes intramuscularly (IM) (anterolateralthigh) until clinical features have improved. Up to 10 doses may be given:– adult dosage: 0.5 mg– paediatric dosage: 0.01 mg/kg (10 μg/kg) (Table 3)– in adults, if there is a poor response, consider glucagon 1–2 mgIV over 5 minutes– consider IV adrenaline if shock persists after two IM doses; use withextreme caution (Table 4)This review article discusses available drugs for the initialmanagement of medical emergencies in general practice.Table 1. General principles in the management of medicalemergencies• Danger, response, airway, breathing, circulation (andcompressions) – DRABC• Activate a crisis resource management plan– get help (eg. other practice staff, ambulance professionalsvia ‘000’, bystanders)– assign roles (including leader, scribe, and timekeeper)– facilitate teamwork• Some history is better than no history– any drugs or allergies?– any ‘not for resuscitation orders’? (Ideally sighted, and on

standardised forms)– if available – ask relatives, check medical records• Give oxygen (8 L/min) via Hudson mask (via bag-valve-masksystem in cardiac arrest)• Intravenous drugs are generally given over 2–5 minutes (butas a ‘push’ with saline flush in cardiac arrest)• Continuous assessment and management until stable• Observe patient once stable (especially if sedative drugshave been administered)• Be willing to consult with an emergency department foradvice and patient transfer• Practise safe sharps management, and follow infectioncontrol procedures• Take detailed notes, and transcribe these to the patient’smedical record at the earliest opportunity. Keep copies ofany transfer of care letters• Arrange debriefing as appropriate for the patient (orrelatives), and for those involved in managing the emergencyReprinted from Australian Family Physician Vol. 37, No. 7, July 2008 541clinical practice Emergency drugs in general practice

• ipratropium 20 μg/dose metered dose inhaler (MDI) via spacer, 2–4puffs every 20 minutes in first hour• hydrocortisone 4 mg/kg IV.If there is no response to inhaled salbutamol, then salbutamolshould be given IV as a bolus (250 μg for adults, 5 μg/kg over 10minutes for children) followed by an infusion. This may not bepractical in most general practice settings. Consider IV adrenaline inextremis (Table 4).Mild/moderateAdult:• oxygen at least 8L/min to maintain SpO2 >94%• salbutamol 100 μg/dose MDI via spacer, 10–20 puffs (4–6 tidalbreaths per puff) every 1–4 hours, or salbutamol 5–10 mg nebulised,driven by oxygen every 1–4 hours• ipratropium 20 μg/dose MDI via spacer, six puffs every 2 hours,OR ipratropium 500 μg nebulised, driven by oxygen every 2 hours(ipratropium is optional)• prednisolone 50 mg orally• Oxygen (8 L/min)• Normal saline (20 mL/kg) is given for hypotension• Hydrocortisone 250 mg (or 4 mg/kg), single dose IV.Potentially life threatening emergenciesAsthma and bronchospasm3

Critical or severe (any of: talking in words, unable to talk, SpO2 <90%,agitated, confused, drowsy, maximal accessory muscle use and recession).Adult:• oxygen, at least 8 L/min to maintain SpO2 >94%• nebulised salbutamol 10 mg driven by oxygen, at least 8 L/min every15 minutes• nebulised ipratropium 500 μg 2 hourly• hydrocortisone 250 mg (or 4 mg/kg) IVPaediatric:• oxygen at least 8 L/min to maintain SpO2 >94%• nebulised salbutamol (5 mg/2.5 mL) driven by oxygen, at least 8 L/min,continuousTable 2. Emergency drugs: presentation, contraindications, and potential adverse reactions (in emergency use)Drug presentation Contraindications (other than known allergy) Adverse reactionsAdrenaline: 1 mg/1 mL(1:1000)Nil in cardiac arrest and anaphylaxis Arrhythmia; myocardial and cerebrovascular

ischaemiaAtropine: 600 μg/1 mL Nil in cardiac arrest or hypotensive bradycardia Tachycardia, confusion, nauseaADT: 0.5 mL vial Children <8 years of age Local: pain, swellingSystemic: fever, malaiseBenztropine: 2 mg/2 mL Children <3 years of age Tachycardia, confusionBenzylpenicillin powder:600 mg or 3 gNil NilDexamethasone: 4 mg/1 mL Nil in emergency Rare with single doseDiazepam: 10 mg/2 mL Cardiorespiratory failureCentral nervous system (CNS) depressionDrowsiness, confusion, respiratorydepressionDihydroergotamine: 1 mg/1 mL Hemiplegic migraineUse of sumatriptanVasospasm syndromes (rare)Frusemide: 20 mg/2 mL Sulfonamide allergy NilGlucagon: 1 mg/1 mL Nil NilGTN spray: 400 μg/dose Cardiogenic shockSystolic blood pressure <100 mmHgUse of phosphodiesterase type 5 (PDE5) inhibitorsHeadache, hypotensionHaloperidol: 5 mg/1 mL Cardiovascular collapseCNS depressionDystonia, confusion, hypotensionHydrocortisone: 100 mg or250 mg/2 mLNil in emergency Rare with single doseLignocaine: 100 mg/5 mL Nil Lightheadedness, nausea, agitationMetoclopramide: 10 mg/2 mL Acute complete bowel obstruction Dystonic reactions (~1%, more common inchildren)Morphine sulphate: 15 mg or30 mg/1 mLRespiratory or CNS depression Sedation, nausea, vomitingNaloxone Min-I-Jet: 0.8 mg/2.0 mLor 2 mg/5 mLNil NilProchlorperazine: 12.5 mg in 1.0 mL Circulatory collapseCNS depressionDrowsiness542 Reprinted from Australian Family Physician Vol. 37, No. 7, July 2008Emergency drugs in general practice clinical practice

Acute coronary syndrome5

• Oxygen 8 L/min• Aspirin 300 mg orally• Glyceryl trinitrate (GTN) spray, 1 dose repeated after 5 minutes if noimprovement• Morphine 2.5 mg IV every 5 minutes as required, titrated to analgesiceffect (maximum of 15 mg).All patients with acute coronary syndrome (ACS) should be stabilisedand transferred to hospital as soon as possible.Fibrinolysis (for ACS with ST elevation or new left bundle branchblock) in an out-of-hospital setting is controversial. Patients who presentto a rural hospital less than 12 hours from symptom onset may beconsidered for fibrinolysis if percutaneous coronary intervention is notpossible within 1–2 hours. A cardiologist should be consulted.Severe upper airway obstruction• Nebulised adrenaline (1 mg in 1 mL ampoules):Paediatric:• oxygen at least 8 L/min to maintain SpO2 >94%• salbutamol 100 μg/dose MDI via spacer, 4–6 tidal breaths per puff,

repeat after 20 minutes for two further doses if not improved– over 6 years of age: 12 puffs– 6 years of age or under: 6 puffsAnd• prednisolone 1 mg/kg orally.Acute exacerbation of chronic obstructive pulmonary disease4

Treat as acute asthma, with the following exceptions:• controlled oxygen therapy to reduce the risk of inducing hyperoxichypercapnia. In practice, oxygen at 2 L/min via nasal prongs isindicated to achieve oxygen saturation of 90–93%• nebulised bronchodilators should be driven with high flow air,not oxygen• start antibiotics for clinical signs of infection (eg. oral doxycycline).Table 2. Emergency drugs: presentation, contraindications, and potential adverse reactions (in emergency use) continuedDrug presentation Contraindications (other than known allergy) Adverse reactionsSalbutamol:MDI: 100 μg/doseNebuliser: 2.5 mg or 5.0 mg/2.5 mLNil Tachycardia, tremorTramadol: 100 mg/2 mL Children, MAOIs, respiratory or CNS depression;caution with SSRI drugsNausea, vomiting, dizzinessVerapamil: 5 mg/2 mL Cardiogenic shock, heart block, hypotension, broadcomplex SVT, use of beta blocker drugsNausea, heart block, bradycardia,hypotensionAspirin*#: 300 mg tablet Active haemorrhage, active gastrointestinal ulcer;caution in asthmaDyspepsiaCeftriaxone*#: 2 g powder Nil NilDiclofenac*:tablets: 50 mgsuppositories: 100 mgActive gastrointestinal ulcer or haemorrhage;caution in: renal impairment, anticoagulation,asthmaNausea, dyspepsiaGlucose*# 50% (500 mg/mL): 50 mL Diabetic coma PhlebitisIpratropium bromide* #:MDI: 20 μg/doseNebuliser: 500 μg/1 mLNil NilKetorolac*: 10 mg/1 mL Active gastrointestinal ulcer or haemorrhage; cautionin: renal impairment, anticoagulation, asthmaNausea, dyspepsiaMidazolam*#: 5 mg in 1 mL(or 15 mg in 3 mL)Cardiorespiratory failureCNS depressionDrowsiness, confusion, respiratorydepressionOlanzapine*: 5 mg wafer or tablet Nil HypotensionSumatriptan*:tablets: 50 mg, 100 mginjection: 6.0 mg in 0.5 mLIschaemic heart diseaseCerebrovascular diseaseErgotamine <24 hour agoCaution: taking SSRI, SNRITransient flushing, dizziness, tightness in

chest or throat, increased BPSyntometrine* 1 mL(oxytocin 5 intra-uterine (IU) plusergometrine 500 μg)Threatened abortionSevere hypertensionHypertensionHeadacheNausea* Not supplied under PBS emergency drug (doctor’s bag) items # Drugs are carried by MICA paramedics in VictoriaMAOI = monoamine oxidase inhibitor, SSRI = selective serotonin reuptake inhibitor, SNRI = selective noradrenaline reuptake inhibitorReprinted from Australian Family Physician Vol. 37, No. 7, July 2008 543clinical practice Emergency drugs in general practice

And/or:• Glucose 50% IV at 3 mL/min via large vein– adult and paediatric dosage: 20–50 mL (depending on response).Convulsive status (convulsion for longer than 10 minutes)• Oxygen 8 L/min• Diazepam– adult dosage: 5–10 mg IV or 10–20 mg per rectum (PR) (insert nozzleof syringe PR, can dilute with 5 mL of saline)– paediatric dosage: (Table 3)Or• Midazolam (dose can be repeated after 15 minutes if there ispersistent or recurrent convulsion)– adult dosage: 5–10 mg IM or 2.5–5.0 mg IV– paediatric dosage: 0.2 mg/kg IM or 0.1 mg/kg IV.Opioid induced respiratory depression• Oxygen 8 L/min• Naloxone– adult dosage:– titrated IV bolus (preferred): 0.1 mg at 1–2 minute intervals– IM (if no IV access): 0.4 mg, repeat every 3 minutes as required (to amaximum of 10 mg)– paediatric dosage: 10 μg/kg IM initially; second dose 100 μg/kg ifrequired.6Titration reduces the risk of precipitating withdrawal symptoms. Patientsshould be observed for renarcotisation; naloxone infusion may berequired.Meningitis and/or meningococcaemia (suspected)• Benzylpenicillin, preferably IV but IM acceptable– adult dosage: 1.2 g– paediatric dosage:– age <1 year: 300 mg– age 1–9 years: 600 mg– age >9 years: 1.2 g– adult dosage: 5 mL– paediatric dosage: 0.5 mL/kg (maximum dose: 5.0 mL); dilute to5.0 mL if necessary.Acute pulmonary oedema• Oxygen 8 L/min – patient must be sitting up• GTN spray, one dose, repeat every 5 minutes as required• Frusemide 20 mg IV (consider 40 mg in patients currently takingfrusemide)• Consider morphine 2.5 mg IV.ArrhythmiasAdults• Cardiac monitoring is essential.• Supraventricular tachycardia (SVT): consider verapamil 5 mg IV over1 minute if symptomatic and if vagal manoeuvres have failed• Bradycardia and ventricular arrhythmias – as described under

‘cardiac arrest’.Adenosine by rapid IV bolus (6 mg then 12 mg if required) is now thedrug of first choice for converting SVT, and GPs may consider this. It ispotentially safer than verapamil, which may result in VF if given to treatVT which has been misdiagnosed as broad complex SVT.Hypovolaemia• Normal saline IV• Adult dosage: 500 mL–1L bolus then infusion to maintain circulation• Paediatric dosage: 20 mL/kg bolus then infusion to maintaincirculation.Postpartum haemorrhage and incomplete abortion• Syntometrine 1 mL IM.Hypoglycaemia• Glucagon IV, IM, or SC– adult (and children over 8 years of age) dosage: 1 mg– children 8 years or under dosage: 0.5 mgTable 3. Paediatric dosage chart for adrenaline and diazepamApproximateageApproximateweight (kg)*Adrenaline1 mg/1mL0.01 mL/kg†

Adrenaline1 mg/10 mL0.1 mL/kg†

Diazepam IV10 mg/2 mL0.04 mL/kgDiazepam PR10 mg/2 mL0.10 mL/kg6 months 8 0.05 mL 0.5 mL 0.2–0.3 mL 0.5–0.8 mL1–2 years 10 0.10 mL 1.0 mL 0.4 mL 1.0 mL2–3 years 15 0.15 mL 1.5 mL 0.6 mL 1.5 mL4–6 years 20 0.20 mL 2.0 mL 0.8 mL 2.0 mL7–8 years 25 0.25 mL 2.5 mL 1.0 mL 2.5 mL9–10 years 30 0.30 mL 3.0 mL 1.2 mL 3.0 mL‡

11–12 years 35 0.35 mL 3.5 mL 1.4 mL 3.0 mL‡

>12 years 40 0.40 mL 4.0 mL 1.6 mL 3.0 mL‡

Note: A useful approximation for a child’s weight is: 9 + (age x 2) kg† = 0.01 mg/kg (10 μg/kg)‡ = maximum recommended dosage544 Reprinted from Australian Family Physician Vol. 37, No. 7, July 2008Emergency drugs in general practice clinical practice

Palliative care emergenciesSeidel et al7 have written a review on the use of doctor’s bag drugs in themanagement of these emergencies.Psychiatric emergencies (adults)Acute psychosis, mania, severe agitation, severe anxiety or panic attack,delirium (pending diagnosis and definitive treatment):• diazepam 5–20 mg orally, or• olanzapine 5 mg orally, or• midazolam 2.5–10.0 mg IM or 2.5–5.0 mg IV every 20 minutes asrequired (especially for drug induced states), or• haloperidol 2.5–5.0 mg IM or IV.With severe disturbance, IV access will be impossible.Dystonic drug reaction:• benztropine IV or IM– adult dosage: 1–2 mg– paediatric dosage: 0.02 mg/kg.

Contaminated woundsCleaning and debridement is the principal management.Adult diphtheria and tetanus (ADT) 0.5 mL IM should be given if:• tetanus prone wound, if more than 5 years since last dose of tetanustoxoid• any wound, if more than 10 years since last dose of tetanus toxoid• uncertainty that primary course has been completed.Emergency drugs provided under the PBSGeneral practitioners can submit a monthly order form to a pharmacistfor the supply of Pharmaceutical Benefits Scheme (PBS) doctor’s bagdrugs at no cost. Alternative drugs may be preferable for managingsome emergencies.• Chlorpromazine may cause hypotension; should be used withextreme caution• Ceftriaxone (if known allergy to penicillin)– adult dosage: 2 g IV or IM– paediatric dosage: 50 mg/kg IV or IM (maximum 2 g)• Dexamethasone (0.15 mg/kg IV (maximum 10 mg)) may also beadministered on specialist advice.Septicaemia (suspected)• Ceftriaxone– adult dosage: 2 g IV or IM– paediatric dosage: 50 mg/kg IV or IM (maximum 2 g).

Nonlife threatening emergenciesNausea and vomitingAdults:• metoclopramide 10 mg, IV, IM or SC• prochlorperazine 12.5 mg IM is effective for nausea and vomitingassociated with vertigo, related to vestibular system disorders.Metoclopramide has a higher risk of dystonic reactions in children thanin adults, and its use in children should be avoided. Metoclopramide hasno place in the management of a child with gastroenteritis.Severe acute pain• Pethidine has no place in the management of pain due to its highpotential for dependence and its neurotoxic metabolites• Consider and exclude drug seeking behaviour before administeringopioids.In most contexts, severe pain can be treated with:• morphine (preferably IV, but can be given IM or SC)– adult dosage: 2.5–5.0 mg, titrate to analgesic effect every 5 minutesup to a maximum of 15 mg– paediatric dosage: 0.1 mg/kg (avoid in infants)• consider an antiemeticOr (for moderate pain in adults):• Tramadol 50–100 mg slow IV or IM.Migraine (adult)• Aspirin 900 mg orally• Metoclopramide 10 mg IV• Normal saline 1 L IV over 1–4 hours• Alternatives to aspirin:– dihydroergotamine 1 mg IM– diclofenac 50–100 mg orally or PR– sumatriptan 50–100 mg orally.Ureteric colic and biliary colicNonsteroidal anti-inflammatory drug (NSAID), eg. diclofenac 100 mg PRor ketorolac 10 mg IM.Painful woundsConsider using plain lignocaine by infiltration, topical application(eg. eyes, ears) or ring block.Table 4. Intravenous adrenaline in low cardiac output states and life threatening asthma

• Ambulance clinical practice guidelines describe the use of diluted incrementaldoses of IV adrenaline every 2 minutes as required to maintain blood pressureand perfusion• Initial doses 10 μg. If there is inadequate response, doses are increased to50 μg and then if necessary to 100 μg• For 10 μg doses, add adrenaline 1 mg to a 1 L bag of normal saline to give asolution of adrenaline 1 μg/mL. Ensure that the bag is labelled. Withdraw10 mL for each dose• For 50 μg and 100 μg doses, add an adrenaline 1 mg/mL 1 mL ampoule to 9 mLof normal saline to give a solution of adrenaline 100 μg/mL. Ensure that thesyringe is labelled. Add the required volume of this solution (0.5 mL or 1.0 mL)to a syringe with 10 mL of normal saline to give the diluted dose of adrenaline• An infusion of normal saline should be running when adrenaline is usedintravenously• IV adrenaline should only be used with extreme caution. Cardiac monitoringis essentialReprinted from Australian Family Physician Vol. 37, No. 7, July 2008 545clinical practice Emergency drugs in general practice

References1. Adult cardiorespiratory arrest flow chart, Australian Resuscitation Council. Availableat www.resus.org.au/public/arc_adult_cardiorespiratory_arrest.pdf [Accessed 19December 2007].2. Emergency management of anaphylaxis in the community. Australian Prescriber2007;30:115. Available at www.australianprescriber.com/upload/pdf/articles/913.pdf [Accessed 19 December 2007].3. National Asthma Council. Emergency management of asthma. Available at www.nationalasthma.org.au/html/emergency/print/EMAC.pdf [Accessed 19 December2007].4. McKenzie DK, Abramson M, Crockett AJ, et al, The COPD-X Plan. Australian andNew Zealand guidelines for the management of chronic obstructive pulmonarydisease, 2007.5. National Heart Foundation. Algorithm for the management of acute coronary syndrome.Available at www.heartfoundation.com.au/downloads/NHF_ACS_chart0506.pdf [Accessed 19 December 2007].6. Clark SFJ, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope.Emerg Med J 2005;22:612–6.7. Seidel R, Sanderson C, Mitchell G, Currow DC. Until the chemist opens – palliationfrom the doctor’s bag. Aust Fam Physician 2006;35:225–31.8. Pharmaceutical Benefits Scheme: Doctors bag emergency drugs. Available at www.pbs.gov.au/html/healthpro/browseby/doctorsbag [Accessed 19 December 2007].9. Brown SGA, Mullins RJ, Gold MS. Anaphylaxis: diagnosis and management. Med JAust 2006;185:283–9.10. Hiramanek N, O’Shea C, Lee C, Speechly C, Cavanagh K. What’s in the doctor’s bag?Aust Fam Physician 2004;33:714–20.• Midazolam is more versatile than diazepam. It can be used to manageconvulsions and agitated states, and, unlike diazepam, can be givenIM, buccally and intranasally. It can be given IV at half the IM dose• Dihydroergotamine is less effective than sumitriptan for relieving thesymptoms of migraine• Haloperidol may cause significant dystonic reactions. Midazolam ispreferable for managing severe agitated states8

• Promethazine has no place in the management of anaphylaxis asit may cause hypotension and vasodilatation. Oral nonsedatingantihistamines are preferable for managing acute urticaria9

• Current emergency management guidelines do not include the use ofeither procaine penicillin or terbutaline.Emergency drugs not provided under the PBSDoctors may obtain these as private items – at their own expense – bysubmitting a written order to a pharmacist. In addition to the non-PBSitems listed in Table 2, the following should be considered:• oral drugs: analgesics, antibiotics, prednisolone, diazepam• normal saline, 1 L bags• normal saline and water for injection.Oxygen

Oxygen is essential for managing emergencies and its availability is arequirement for general practice accreditation. Oxygen cylinders canbe hired and refilled from a medical gas supplier (eg. BOC). A size Ccylinder (490 L) will last for 55 minutes at 8 L/min.The following are required to administer oxygen: adult and paediatricHudson masks and nebuliser masks, nasal prongs, airways, and a bagvalve-mask breathing system (eg. Air Viva 3).Equipment for managing emergenciesAppropriate supplies of IV infusion sets, cannulas, syringes, and needlesare required. General practitioners should consider the following itemsfor their practices:• an automated external defibrillator (AED) with monitor and manualoverride. Although a defibrillator is not a requirement for practiceaccreditation, its absence may put a practice at clinical andmedicolegal risk• pulse oximeter• portable packs to enable equipment to be taken for use offsite.Equipment for the doctor’s bag is discussed in detail by Hiramaneket al.10

Managing emergency drugs in general practiceDrugs must be stored in a locked cupboard or a locked bag at less than25°C. ADT and syntometrine are stored in a refrigerator. Schedule 8drugs (opioids) must be stored in a locked, fixed, steel safe; althoughampoules may be put in a locked bag for use away from the clinic.All emergency drugs should be logged in a book or spreadsheet thatincludes date received, date administered, recipient, and expiry date.Systems should be in place for checking drug stocks and expiry dates,and for auditing the log.A separate book is required to log Schedule 8 drugs received andused. A Schedule 8 drug record book is available from The RoyalAustralian College of General Practitioners at www.racgp.org.au/publications/recordkeeping.Conflict of interest: none declared. correspondence afp@racgp.org.au546 Reprinted from Australian Family Physician Vol. 37, No. 7, July 2008

http://www.racgp.org.au/afp/200807/200807baird.pdf

Flashcards: Emergency Cardiogenic Shock Drugs

Both Sides

furosemideLoop diuretics used in emergency management of heart failure

1/28

Study:

Speller

Learn

Test

Play Games:Scatter

Space Race

All 28 termsPrint new! Export Combine

Terms Definitions

furosemideLoop diuretics used in emergency management of heart failure

Nitroglycerine, Nitroprusside, Hydralazine, Isosorbide dinitrate

vasodilators used in emergency management of heart failure

Dobutamine, Dopamine, BipyridinePositive inotropes used in emergency management of heart failure

action of loop diureticsthese drugs will reduce blood volume and decrease preload/vol overload and improve heart function and decrease edema formation

inhibit of Na-K-2Cl MOA of loop diuretics

orally & IV how are loop diuretics given?

vol depletion, electrolyte imbalances, systemic alkalosis

major adverse effects of loop diuretics?

actions of vasodilatorsthese drugs used in emergency heart failure with cause arterial dilation and venous dilation to reduce afterload and preload

veins nitroglycerine mainly dilates....

formation of NO MOA of nitroglycerine

topically route of administration of nitroglycerine

excessive VD decreasing BP adverse effects of nitroglycerine

both veins and arteries nitropruside maily dilates....

formation of NO MOA of nitroprusside

IV route of administration of nitroprusside

cyanogenimportant metabolite of nitroprusside that is eliminated in urine, feces and exhales

excessive VD (more likely then nitroglycerine) & cyanide toxicity with tolerance

adverse effects of nitroprusside

arterial Hydralazine (orally) mainly dilates...

venodilator what is isosorbide dinatrate

beta 1what receptor(s) does dobutamine act on to increase ionotropy and chronotropy?

IV (degraded in GI so no oral admin) route of administration of Dobutamine

systolic heart failure (DCM) what type of heart disease is best to use Dobutamine?

valvular regurg and decreased contractility

Dobutamine is contraindicated in what types of heart failure?

tachyarrhythmias adverse effects of Dobutamine

mid dose what dose is Dopamine used at in heart disease?

Amrinone and MilrinoneBipyridines used as positive ionotropes in emergency heart failure

actions of Bipyridinesdrug used in emergency heart failure to increase contractility and cause VD.

systolic heart failure Bipyridines are contraindicated in what type of heart failure?

Set Champions

There are no high scores or champions for this set yet. You can sign up or log in to be the first!

Completed “Learn” mode

EPurbi

http://quizlet.com/2542924/emergency-cardiogenic-shock-drugs-flash-cards/

Reasons why the chance of an emergency occurring in the dental office continues to increase

1-The average age of the dental patient has increased2-Dental offices are administering more complicating drug regimens3-Dental appointments are taking longer4-Dental patients, on average, are getting sicker

1/18

Study:

Speller

Learn

Test

Play Games:Scatter

Space Race

All 18 termsPrint new! Export Combine

Terms Definitions

Reasons why the chance of an emergency occurring in the dental office continues to increase

1-The average age of the dental patient has increased2-Dental offices are administering more complicating drug regimens3-Dental appointments are taking longer4-Dental patients, on average, are getting sicker

General Measures to prepare the -Train

dental office for an emergency

-Phone #s of closest physician, ER, and ambulance service (911)-Emergency kit (should be well-stocked)-CPR training: required-Advanced Cardiac Life Support Training: optional, unless performing conscoius sedation

Primary Importance in Emergency

A= Airway (maintenance)B= Breathing (oxygen administration)C= Circulation (monitoring vital signs)If needed:D= Defibrilation (AED)-Drugs are not important for the proper management of most emergencies

Syncope-Emergency most often encountered in dental office-Diaphoresis: sweating-Sudden fall in BP

Treatment for Syncope

-Place patient in Trendelenburg position (head down)-Exhibit confidence in action and voice to avoid repeated syncopal attack-Administer spirits of ammonia by inhalation

Treatment for Hypoglycemia Conscious: glucose

Asthma

-Patient's own medication (multiple dose inhalers containing a B2-agonist such as albuterol) should be used first-Dose should be repeated several times-If no response, 911-hospitalization for administration of aminophylline, parenteral corticosteroids, and epinephrine

Anaphylactic Shock

-The most common cause is injection of penicillin-DRUG OF CHOICE IS PARENTERAL EPINEPHRINE (MUST BE ADMINISTERED IMMEDIATELY; MAY BE GIVEN IN THE DELTOID OR INJECTED UNDER THE TONGUE)-Other medications used after epi may include albuterol, IV corticosteroids, diphenhydramine (BENEDRYL), and aminophylline

Treatment for Acute Airway Obstruction

-Place pt in Trendelenburg position on the right side and encourage coughing-Do not allow the pt to sit up-Clear the pharynx and pull the tongue forward

-Heimlich maneuver-911- cricothyrotomy or tracheotomy if unsuccessful by other methods

Angina Pectoris Treated with sublingual nitroglycerin

Acute MI Unrelieved by 3 doses of nitroglycerin

Cardiac Arrest-Immediate CPR-911-AED

Thyroid Storm-Hyperthyroidism is out of control-Tx: tepid baths and aspirin to control temperature

Malignant Hyperthermia

-Triggered by inhalation of general anesthetics or neuromuscular blocking agents such as succinylcholine-Tx: baths & aspirin, dantrolene (dantrium), fluid replacement, steroids, sodium bicarbonate

Opiod Overdose Drug of choice= nalaxone (Narcan)

Toxic reactions to epinephrine-Occur most after the placement of a gingival retraction cord used before taking impressions-Tx: remove cord and reassure the patient

Level 1 (Critical) Drugs

1-Epinephrine2-Diphenhydramine (Benedryl)3-Oxygen4-Nitroglycerin5-Glucose6-Albuterol7-Aspirin8-Aromatic Ammonia Spirits (also level 2)

Emergency Equipment1-Oxygen Delivery System2-Sphygmomanometer & Stethescope3-AED

Set Champions

There are no high scores or champions for this set yet. You can sign up or log in to be the first!