1. Emergency Drugs Introduction Purpose of Emergency Drugs Details of Emergency Drugs -Description of the Drug -Mechanism of Action -Indication and Dose of the Drug -Drug Interaction -Contraindications -Adverse Effects of the Drug -Nursing Considerations
2. Introduction Emergency drugs are those chemical entity used in patients during life threatening conditions so that the symptoms can be controlled and the life of a patient can be saved. Emergency drugs are usually available in those kind of dosage forms having short onset of action. i.e rapid/prompt action. Emergency Drugs are used in those patients requiring immediate attention.
3. Purpose of Emergency Drugs To provide initial treatment for board spectrum of illness and injuries, most of which may be life threatening. To control the symptoms of patient. To save the life of the patient. To reach the site of action as soon as possible. To normalize the vital bodily functions. To diverge the patient from the possible risks.
4. List of Drugs Atropine Adrenaline Noradrenaline Dopamine Hydrocortisone Midazolam Ondensteron Dextrose 50% Dextrose 25%
5. Atropine(Anticholinergic/Antimuscarinic)Description of the drug: Atropine Sulfate Injection, USP is a sterile, non- pyrogenic isotonic solution of atropine sulfate monohydrate in water for injection with sodium chloride sufficient to render the solution isotonic. It is administered parenterally by subcutaneous, intramuscular or intravenous injection. Each milliliter (ml) contains atropine sulfate, monohydrate 0.1 mg (adult strength) or 0.05 mg (pediatric strength), and sodium chloride, 9 mg. The solution contains no bacteriostatic, antimicrobial agent or added buffer (except for pH adjustment) and is intended for use only as a single-dose injection.
6. AtropineMechanism of Action: It competitively blocks the muscarinic receptors in peripheral tissues (heart, intestines, bronchial muscles, iris, secretory glands) and relaxes the smooth muscles. The main action of vagus nerve of the parasympathetic system on the heart is to slow it down and atropine blocks that action and speed up the heart rate.
7. AtropineIndications and dose of the drug: Bradycardia: 0.5-1mg repeated every 3-5 min when necessary in adults. Organophosphorus poisoning: 2mg iv/im every 3 min. according to clinical response in adult. Overdose with other compounds having muscarinic actions: 0.5mg-1mg iv/sc repeated every two hours. Cardiac arrest: 1mg every 3-5 minutes. To reduce vagal tone, salivary and bronchial secretion in Anaesthesia: 300-600mcg im/sc 30-60 min before anaesthesia in adult.
8. AtropineDrug Interactions: The effect of the drug increases with- Quinidine (Antiarrhythmic) Amitriptyline (Antidepressants) Diphenhydramine (antihistamine) Meclizine (antihistamine)
11. AtropineNursing Consideration: Initially heart rate may increase, so access vital signs. Monitor constipation and oliguria. Patient should told not to drive for an hour or two after mydriasis. Following parenteral administration postural hypotension may occur if patient ambulates too soon after the drug is given. Encourage drinking frequent fluid, sips of water or chewing gum to relief dry mouth. Inform the patient that his pupil will be dilated and vision blurred and caution him to avoid activities requiring visual acuity.
12. Adrenaline (Direct acting Adrenergic agonist)Description of the drug: Adrenaline Injection is a clear, colourless solution. Adrenaline 1.8mg/ml contains adrenaline bitartrate as the active ingredient, plus * Sodium metabisulfite (1.0mg) * Sodium chloride (8.0mg) * Sodium hydroxide or HCl for pH. * Water for Injections. Adrenaline is a hormone and a neurotransmitter. It increases heart rate (b1), constricts blood vessels (a1), dilates air passages (b2) and participates in the fight-or-flight response of the sympathetic nervous system. Chemically, adrenaline is a catecholamine, a monoamine produced only by the adrenal glands from the amino acid, phenylalanine and tyrosine.
13. Adrenaline Mechanism of action  It acts by stimulating the à and ß- receptors of the adrenergic neurons of sympathetic nervous system. Adrenoceptors Actionsà1-receptors Vasoconstriction, increased BP, Mydriasisà2-receptors Inhibits the release of noradrenaline, acetylcholine and insulinß1-receptors Tachycardia, increase lipolysis, myocardial contractility and renin.ß2-receptors Vasodilation, bronchodilation, relaxes uterine smooth muscle.
14. AdrenalineIndication and dose of the drug: Cardiac Arrest: 1mg IV of 1:10000 solution every 3-5 minutes or iv bolus(10ml) Anaphylaxis (type 1): iv bolus, 0.5-1.0ml, may be repeated when necessary Refractory bradycardia and hypotension: 2- 10mcg/min. Asthma: 0.1-0.3mg SC or IM of 1:10,000 solution.
15. AdrenalineDrug Interactions: Cocaine: Increases the cardiovascular effects of adrenaline. Insulin: action of insulin decreases. Hyperthyroidism: Activity of adrenaline may increase.
16. AdrenalineContraindications: Narrow angle glaucoma Shock (other than anaphylactic shock) Individuals with organic brain damage Labor (may delay second stage) Coronary insufficiency Pregnant and breast feeding mothers.
17. AdrenalineAdverse effects of the drug: CNS: anxiety, fear, tension, headache, and tremor. Hemorrhage: The drug may induce cerebral hemorrhage as a result of a marked elevation of blood pressure. Pulmonary edema Less serious side effects may include: sweating, nausea and vomiting, pale skin, feeling short of breath, dizziness, weakness or tremors, headache, or feeling nervous or anxious.
18. AdrenalineNursing consideration: Monitor VS and check for cardiac dysrrhythmias. Avoid IM use of parenteral suspension into buttocks as gas gangrene may occur. Massage site after IM injection to counter possible vasoconstriction. Rotate injection site. Observe patient closely for adverse reactions. Never give fast IV except for cardiac resuscitation, it may cause ventricular fibrillation, premature contraction. Store medicine tightly covered, light resistant container.
19. Noradrenaline (Direct actingadrenergic agonist)Description of the drug: Noradrenaline is a catecholamine with multiple roles including as a hormone and a neurotransmitter. Noradrenaline is a sterile aqueous solution in the form of the bitartrate salt to be administered by intravenous infusion following dilution. Each ml contains the equivalent of 1 mg base of Noradrenaline, sodium chloride for isotonicity, and not more than 2 mg of sodium metabisulfite as an antioxidant. It has a pH of 3 to 4.5.
20. NoradrenalineMechanism of action: As it the neuromediator of all adrenergic nerves, it acts by stimulating all kinds of adrenergic receptors. Noradrenaline causes a rise in peripheral resistance due to intense vasoconstriction of most vascular beds, including the kidney. And both systolic and diastolic blood pressures increases.
21. NoradrenalineIndication and dose of the drug: Acute Hypotensive states (eg. Pheochromocytomectomy, sympathectomy, poliomyelitis, spinal anesthesia, myocardial infarction, septicemia, blood transfusion and drug reactions) As an adjunct in treatment of cardiac arrest and profound hypotension. Average Dosage: Add a 4 mL vial (4 mg) of norepinephrine to 1,000 mL of a 5% dextrose containing solution. Each mL of this dilution contains 4 mcg of the base of norepinephrine. Give this solution by intravenous infusion.
22. NoradrenalineDilution of the drug: Noradrenaline should be diluted in 5% dextrose injection or 5% dextrose and sodium chloride injections. Administration in saline solution alone is not recommended. Whole blood or plasma, if indicated to increase blood volume, should be administered separately (for example, by use of a Y-tube and individual containers if given simultaneously).
23. Noradrenaline Drug interactions:  Amytriptylline: Activity of noradrenaline increases.  Halothane: Sensitizes the heart to arrhythmogenic effects of noradrenaline  Trimipramine: Activity of noradrenaline increases.
24. NoradrenalineContraindications: It should not be administered to maintain blood pressure in the absence of blood volume replacement. Mesenteric or peripheral vascular thrombosis. Profound hypoxia or hypercarbia. hypersensitivity
25. NoradrenalineAdverse effects of the drug: Ischemic injury due to potent vasoconstrictor action and tissue hypoxia. Anxiety Transient headache Respiratory difficulty Extravasation necrosis at injection site. intense sweating, and vomiting.
26. NoradrenalineNursing consideration: Blood pressure should be checked frequently throughout treatment. Leakage of this medicine from the veins at the site of injection can cause death of the tissue in that area. The infusion site should be checked frequently. It should not be given to hypovolaemic patients except in emergencies. Administration in saline solution alone is not recommended. Use whole blood or plasma along with Y tube if it is indicated to increases blood volume
27. Dopamine Hydrochloride (Direct acting adrenergic agonist)Description of the drug: Dopamine Hydrochloride Injection, USP is a clear, sterile, non-pyrogenic, practically colorless, aqueous, additive solution for intravenous infusion after dilution. Each ml contains either 40 mg, 80 mg, or 160 mg dopamine HCl, USP, in Water for Injection, containing 9 mg sodium metabisulfite as an antioxidant.
28. Dopamine HydrochlorideMechanism of Action: The action is accomplished by exerting agonist effects on the beta-adrenoceptors in heart causing complete or forceful contractions. It additionally acts on the dopaminergic receptors in renal and mesentric blood vessels and dilates them.
29. Dopamine HydrochlorideIndications and dose of the drug: Hemodynamic imbalances present in shock syndrome caused by: -Hypovolaemia (blood volume should be restored with plasma volume expander before dopamine administration) -Myocardial Infraction -Trauma -Septicaemia -Acute renal failure -Open heart surgery -Congestive failureDose: 2-5 mcg/kg/min can be increased up to 10 mcg/kg/min by slow iv infusion in adult. If the dose exceeds 50 mcg/kg/min, then access the renal function of the patient. (1mg=1000mcg)
30. Dopamine HydrochlorideDrug Interactions: Beta-blockers: Antagonizes the cardiac effects of dopamine. Methyl dopa: hypertension may occur Alpha-blockers: Antagonizes the peripheral vasoconstriction caused by high dose dopamine. Diuretics: Action of diuretic drug increases. Phenytoin: Hypotension and bradycardia may increases when co administered with dopamine.
31. Dopamine HydrochlorideContraindication: Pheochromocytoma (tumor of medulla of adrenal glands) Tachyarrhythmias ventricular fibrillation (uncoordinated contraction of cardiac muscle of ventricles in the heart) Hypersensitivity: Especially allergy to corn products (dextrose solutions).
32. Dopamine HydrochlorideAdverse effects of the drug:Cardiovascular System: ventricular arrhythmia (at very high doses) ectopic beats (irregularity of heart rate) Anginal pain palpitation widened QRS complex vasoconstrictionRespiratory System: Dyspnea Asthma attacks
33. Dopamine HydrochlorideAdverse effects of the drug:Gastrointestinal System: nausea VomitingMetabolic System Azotemia (elevated BUN) hyperglycemiaCentral Nervous System: headache anxietyDermatological System: Piloerection (involuntary erection of hairs)
34. Dopamine HydrochlorideNursing Considerations: Check the vital signs regularly and carefully. During infusion, monitor ECG, BP, CO, PR and color and temperature of limbs. Don’t use solution darker than slightly yellow or discolored yellow, brown or pink to purple, indicates decomposition of the drug. The reconstituted solution should be used with in 24 hours. Blood volume depletion must be corrected. For IV infusion administer in to large veins to prevent extravasation, use infusion pump to control rate of flow. When discontinuing, gradually decrease dose as sudden cessation may cause marked hypotension. Do not confuse dopamine to dobutamine. Check urine output often.
35. “Thank You”
36. Hydrocortisone (Corticosteroids)Description of the drug: Hydrocortisone sodium succinate is an anti- inflammatory adrenocortical steroid. This highly water-soluble sodium succinate ester of hydrocortisone permits the immediate intravenous administration of high doses of hydrocortisone in a small volume of diluent and is particularly useful where high blood levels of hydrocortisone are required rapidly. This sterile powder is available for intravenous or intramuscular administration.
37. HydrocortisoneMechanism of action: It reduces the inflammatory reaction by limiting the capillary dilatation and permeability of the vascular structures. It also restrict the accumulation of polymorphonuclear leukocytes and macrophages and reduce the release of vasoactive kinins. It also inhibit the release of destructive enzymes that attack the injury debris and destroy normal tissue indiscriminately.
38. HydrocortisoneIndication and dose of the drug: Acute adrenocortical insufficiency Congenital Adrenal hyperplasia Hypercalcemia associated with cancer Juvenile rheumatoid arthritis Epicondylitis Systemic lupus erythematous Exfoliative dermatitis Seborrheic dermatitis Optic neuritis
39. HydrocortisoneIndication and dose of the drug: Ulcerative colitis Aspiration pneumonitis Erythroblastopenia Multiple Sclerosis *The initial dose of hydrocortisone is 100 mg to 500 mg, depending on the severity of the condition. This dose may be repeated at intervals of 2, 4 or 6 hours as indicated by the patient’s response and clinical condition. *Therapy is initiated by administering hydrocortisone sterile powder intravenously over a period of 30 seconds (eg, 100 mg) to 10 minutes (eg, 500 mg or more).
40. HydrocortisoneDrug interactions: Drugs such as phenobarbital, phenytoin and rifampin induces hepatic enzymes and increases the clearance of hydrocortisone. Drugs such as troleandomycin and ketoconazole may inhibit the metabolism of hydrocortisone and thus decrease their clearance. When used with high dose aspirin, clearance of asprin increases.
42. HydrocortisoneAdverse effects of the drug: Sodium retention Congestive heart failure in susceptible patients Potassium loss Hypokalemic alkalosis Hypertension Convulsions Vertigo Headache Abdominal distention Loss of muscle mass
43. HydrocortisoneNursing Considerations: For best result dose should be given early in the morning. Give after food on a full stomach. Give IM injection deeply into the gluteal muscle, rotate injection sites to prevent tissue atrophy. Do not give in the deltoid; do not inject subcutaneously. The patient should never change or stop the dosage except as directed.
44. HydrocortisoneNursing Considerations: Monitor I/O chart and vital signs, notify doctor if patient BP increases while taking medicine. Assess serum glucose, electrolyte, platelets and other problems as muscle weakness, wasting, sign of negative nitrogen balance. Daily weight the patient. Rapid weight gain is usually an indication of fluid and sodium retention. Monitor side effects including patient’s mood change, depression and report to the doctor as changes take place. Never stop the drug suddenly, it should be stopped after tapering the dose.
45. Midazolam (Short actingBenzodiazepine)Description of the drug: Midazolam is a water-soluble benzodiazepine available as a sterile, non pyrogenic parenteral dosage form for intravenous or intramuscular injection. Each mL contains midazolam hydrochloride equivalent to 1 mg or 5 mg midazolam compounded with 0.8% sodium chloride and 0.01% edetate disodium with 1% benzyl alcohol as preservative, and sodium hydroxide and/or hydrochloric acid for pH adjustment. pH 2.9-3.7.
46. MidazolamMechanism of action: It acts by binding to GABA –A receptors (post synaptic receptors) and increases it’s frequency of opening, leading to potentiate the GABA effects. This opening leads to a increased conductance to chloride ions, which produces membrane hyperpolarization, this induces a neuronal inhibition which results in its sedative action.
47. MidazolamIndication and dose of the drug: Sedation and amnesia Sedation—Midazolam is indicated for the sedation of patients in intensive care settings, including intubated patients receiving mechanical ventilation Anesthesia, general, adjunct Status epilepticus
48. MidazolamIndication and dose of the drug: The initial intravenous dose for sedation in adult patients may be as little as 1 mg, but should not exceed 2.5 mg in a normal healthy adult. Lower doses are necessary for older (over 60 years) or debilitated patients and in patients receiving concomitant narcotics or other central nervous system (CNS) depressants. The initial dose and all subsequent doses should always be titrated slowly; administer over at least 2 minutes and allow an additional 2 or more minutes to fully evaluate the sedative effect. The use of the 1 mg/mL formulation or dilution of the 1 mg/mL or 5 mg/mL formulation is recommended to facilitate slower injection.
49. MidazolamDrug interactions: Caution is advised when midazolam is administered concomitantly with drugs that are known to inhibit the P450 3A4 enzyme system such as cimetidine (not ranitidine), erythromycin, diltiazem, verapamil, ketoconazole and itraconazole. These drug interactions may result in prolonged sedation due to a decrease in plasma clearance of midazolam.
50. MidazolamContraindications: Hypersensitivity Acute narrow angle glaucoma Shock Hypotension or head injury
51. MidazolamAdverse effects of the drug: headache drowsiness nausea vomiting hiccups coughing pain, redness, or hardening of the skin at the injection site agitation restlessness uncontrollable shaking of a part of the body stiffening and jerking of the arms and legs aggression seizures uncontrollable rapid eye movements hives rash itching difficulty breathing or swallowing
52. MidazolamNursing Considerations: The dose must be individualized based on age, underlying disease and desired effect. Deep IM should be given in large muscle mass. Resuscitate equipment should be at hand before giving intravenous midazolam. Monitor respiratory rate continuously during parenteral administration for respiratory depression apnea. Monitor cardiac function continuously.
53. Ondansetron Hydrochloride(Antiemetic/ Selective SerotoninReceptor Antagonist)Description of the drug: It is a new class of antiemetic drug developed to control cancer chemotherapy and radiotherapy induced nausea and vomiting and also effective to control post operative nausea and vomiting. Ondansetron hydrochloride injection is a clear, colorless, nonpyrogenic, sterile solution. The pH of the injection solution is 3.3 to 4.0.
54. OndansetronMechanism of action: The mechanism of action of ondansetron is related to its peripheral (vagus nerve terminal) and central (CTZ) 5-HT3 receptor blocking properties.
55. OndansetronIndication and dose of the drug: Prevention and management of nausea and vomiting due- -Chemotherapy -Radiotherapy -Post operative. Adult Population - A single 32 mg dose infused over 15 minutes beginning 30 minutes before the start of emetogenic chemotherapy.
56. OndansetronDrug interactions: Apomorphine – profound hypotension and loss of consciousness may occur. Carbamazepine, Pheytoin and rifampicin: In patients treated with potent inducers of CYP3A4 the clearance of ondansetron was significantly increased and ondansetron blood concentrations were decreased.
57. OndansetronContraindications Hypersensitivity Other no any significant
58. OndansetronAdverse effects of the drug:Common side effects Headache Dizziness Constipation or diarrhoeaSevere side effects Allergic reaction breathing problem Fast or irregular heartbeat bradycardia Fever and chills Swelling of the hand Urinary retention Xerostomia
59. OndansetronNursing Consideration: Assess for dehydration if excessive vomiting ocurrs, provide emotional support. Store the injection at room temperature and reconstituted solution can be used for 48 hrs after dilution. The medicine may come in undiluted. For IV infusion, dilute with 50ml dextrose 5% or 0.9% Nacl, DNS before administration. For IV bolus, give slow IV push over 2-5 minutes or IV infusion over 15 minutes.
60. Dextrose (50%)(Carbohydrate/Hypertonic/Caloric)Description of the drug: The term dextrose is used to describe the six-carbon sugar d-glucose, the principal form of carbohydrate used by the body. D50 is used in emergency care to treat hypoglycemia and to manage coma of unknown origin.
61. Dextrose 50%Indication and dose of the drug: Documented hypoglycemia Seizures of unknown etiology Cerebral/meningeal edema related to eclampsia Coma of unknown cause Refractory cardiac arrest Adult dose: 12.5 - 25 gm D50W slow IV, repeat if needed.
62. Dextrose 50%Drug interaction: There are no significant contraindications for IV administration of 50% dextrose in emergency care.
63. Dextrose 50%Adverse effects of the drug: Pain Phlebitis at injection site Hyperglycemia and glycosuria Fluid overload rhabdomyositis
64. Dextrose 50%Nursing Considerations: Draw blood sample before administration if possible. Dextrose 50% has an acidic pH (3.5 - 5) and therefore specific compatibility information should be consulted when Dextrose 50% is injected into an IV line containing another drug. Rapid rates of administration predisposes the patient to pain and may cause phlebitis if a peripheral vein is used; to minimize this effect administer slowly Extravasation may cause tissue necrosis; use a large vein and aspirate occasionally to ensure route patency. Excessive IV administration may cause fluid overload, water intoxication, CHF, so should be cautiously adminstered. D50W and Thiamine 100 mg IV (mini bag or IVP) should be given together when alcoholism or malnutrition are suspected.
65. Dextrose 25%Description of the drug: 25% Dextrose Injection, USP is a sterile, non-pyrogenic, hypertonic solution of dextrose in water for injection administered by intravenous injection to restore blood glucose levels in hypoglycemia and as a source of carbohydrate calories. Each milliliter (ml) of fluid contains dextrose, hydrous, 250 mg which delivers 3.4 kcal/gram (0.85 kcal/ml).
66. Dextose 25%Indication and dose of the drug: Acute symptomatic episodes of hypoglycemia in the neonate or older infants: It restores depressed blood glucose levels and control symptoms. Oral feeding of dextrose may be necessary in infants with frequently recurring hypoglycemic episodes or to prevent recurrences due to hyperinsulinemia. 25% Dextrose Injection also provides a minimal source of carbohydrate calories.
67. Dextrose 25%Dose of the drug: In the neonate, an injection of 250 to 500 mg (1 to 2 mL)/kg/dose (5 to 10 mL of 25% dextrose in a 5 kg infant) is recommended to control acute symptomatic hypoglycemia. Larger or repeated single doses (up to 10 or 12 mL of 25% dextrose) may be required in severe cases or older infants.
68. Dextrose 25%Drug interaction: There are no significant contraindications for IV administration of 50% dextrose in emergency care.
69. Dextrose 25%Contraindications: A concentrated dextrose solution should not be used when intracranial or intraspinal hemorrhage is present.
70. Dextrose 25%Adverse effects of the drug: Mental confusion Loss of consciousness. Infection at the site of injection Venous thrombosis
71. Dextrose 25%Nursing Considerations: Do not administer unless the solution is clear and seal is intact. Frequent monitoring of serum glucose concentrations is required when intravenous dextrose is given to pediatric patients, particularly neonates and low birth weight infants. Solutions containing dextrose should be used with caution in infants of diabetic mothers except as may be indicated in neonates who are hypoglycemic.
72. Dextrose 25%Nursing Considerations: Care should be exercised to insure that the needle is well within the lumen of the vein and that extravasation does not occur. If thrombosis should occur during administration, the injection should be stopped and corrective measures instituted. Concentrated dextrose solutions should not be administered subcutaneously or intramuscularly.
74. References: Baynes, J., Dominiczak, M., Medical Biochemistry. Elsevier Limited; Third Edition (2009) Goodman E (2010). Ketchum J, Kirby R. ed. Historical Contributions to the Human Toxicology of Atropine. Eximdyne. pp. 120. Britto MR, Hussey EK, Mydlow P, et al. Effect of enzyme inducers on ondansetron (OND) metabolism in humans. Clin Pharmacol Ther 1997;61:228. Villikka K, Kivisto KT, Neuvonen PJ. The effect of rifampin on the pharmacokinetics of oral and intravenous ondansetron. Clin Pharmacol Ther 1999;65:377-381. Bryan E, Bledsoe; Robert S. Porter, Richard A. Cherry (2004). "Ch. 3". Intermediate Emergency Care. Upper Saddle River, NJ: Pearson Prentice Hill. pp. 26.
75. References: Nursing Spectrum Drug Handbook 2009, by The McGraw- Hill Companies, Inc. Georgievski Z, Koklanis K, Leone J. Fixation behaviour in the treatment of amblyopia using atropine. Clinical and Experimental Ophthalmology 2008; 36 (Suppl 2): A764– A765. Rang HP, Dale MM, Ritter JM, Flower RJ (2007). "Ch. 10". Rang and Dales Pharmacology. Elsevier Churchill Livingstone. pp. 153. Bochner, F. Australian Medicines Handbook. Australian Medicines Handbook Pty Ltd. Adelaide 2005; pp 2-5.
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