Pharmacology of drugs in

Emergency cases

Prof.dr.Aznan Lelo,PhD SpFK

dr.Datten Bangun,MSc,SpFK
Dept.Farmakologi & Therapeutik
Fak.Kedokteran USU
MEDAN
Medical Emergencies in the Office
ƒ Allergic reactions / ƒ Acute asthma
anaphylaxis ƒ Dystonic reactions
ƒ Oversedation / vomiting ƒ Hyperthermia
ƒ Syncope ƒ Hypertensive crisis
ƒ Severe hyperventilation ƒ Foreign body aspiration
ƒ Bleeding disorders ƒ Diabetic hypoglycemia
ƒ Acute chest pain ƒ Addisonian crisis
ƒ Seizures ƒ Obstetrical concerns
ƒ Strokes (CVA's) ƒ Mandibular dislocation
 Major Effects of Anaphylactic Mediators
ƒ Vasodilation
ƒ Smooth muscle spasm
ƒ Increased vascular permeability
ƒ Edema formation

Causes of Death from Anaphylaxis

ƒ Upper airway edema : 70 % of deaths
ƒ Circulatory collapse : 20 %
ƒ Both : 10 %
 Anaphylaxis : Causes
ƒ Antibiotics : most common
ƒ Local anesthetics
ƒ Latex
–Should question all patients about latex allergy ; If
allergic, use plastic or nitrile gloves, nozzles, etc.
–Food
–Insect bite
Emergent Treatment of Systemic
Allergic Reaction
ƒStart this sequence if VS not OK (increased HR,
decreased BP, or any throat tightness, SOB or
wheezing) :
–1. Place patient recumbent / supine (to prevent
empty ventricle syndrome) & start FMO2
–2. SQ epi 0.3 mg (0.01 mg / Kg) ; rub area ; If
hypotensive : dilute epi (1:10,000) & give 0.1 to 0.2 mg
IV slowly (never more than 0.1 mg IV at a time)
–3. IV diphenhydramine or hydroxyzine 1 mg / Kg (50
mg in adults)
–4. IV steroids (100 mg hydrocortisone)
Emergent Treatment of Systemic
Allergic Reaction (cont.)
ƒ5. IV fluid bolus (LR or NS 1 liter or 20 cc / Kg)
ƒ6. Metaproteronol or albuterol aerosol if
wheezing (0.2 to 0.5 cc in 3 cc NS)
ƒ7. Consider IV ranitidine or cimetidine
ƒ8. Atropine if bradycardic
Dopamine if hypotensive despite IV fluids
Racemic epi aerosol if throat swelling
Early intubation if airway compromise
 2. Hypoglycemia
ƒ Usually IDDM patient
–Decrease PO intake
–Increase activity (exercise)
ƒ Also in NIDDM patient
–Oral hypoglycemic drugs cause longer duration
hypoglycemia than does insulin excess
–-patient on OAD,when consuming NSAIDs,then
NSAIDs will displace OAD from protein binding -----
>OAD intoxication------hypoglicemia
 Hypoglycemia

ƒ Can occur in non-diabetic patient :

–ETOH ingestion
–Toxic salicylate ingestion
–Malnourished states
–Insulin-producing tumors
ƒ Patients on beta blockers susceptible
 Hypoglycemia : Symptoms
(any of these may be present)
ƒ Anxiety ƒ May have seizure or
ƒ Sleepiness coma
ƒ Lethargy ƒ Fatigue
ƒ Cold, clammy skin ƒ Confusion
ƒ Weakness ƒ Palpitations
ƒ Dizziness ƒ Tremulousness
ƒ Lightheadedness ƒ Sweating
ƒ Headache ƒ Hunger
ƒ Any focal neuro sign ƒ Combativeness
 Hypoglycemia : Treatment
ƒ 1. If reasonably alert and able to manage own airway,
then give glucose-containing gel or fluid PO
ƒ 2. Otherwise start IV (draw red top or green top tube of
blood if possible also so that diagnosis can be
confirmed later in lab) and give 1 amp (50 cc) of 50 %
dextrose in water (for child give 1 gm / kg IV of 25 %
dextrose in water)
ƒ 3. May need to repeat dose once
ƒ 4. If unable to start IV : consider glucagon 1 mg IM (only
works if glycogen stores OK in liver)
ƒ 5. Call EMS if patient not a known diabetic or if no rapid
response to initial treatment with sugar
ƒ Important to diagnose and treat quickly to prevent
hypoglycemic neuronal damage
 3. Hypertension Emergencies
ƒ Hypertensive crisis (emergency) :
–Severe elevation in blood pressure with
rapid or progressive CNS, cardiac, renal, or
hematologic deterioration
ƒ Hypertensive " urgency " :
–Elevated BP but no symptoms of end-
organ damage
–BP reduction over 24 to 48 hrs.
recommended
 Causes of Hypertensive Crises
ƒ Accelerated hypertension
–Hypertensive encephalopathy (malignant
hypertension)
–Uncontrolled primary hypertension
–Renal vascular disease
–Toxemia of pregnancy
–Pheochromocytoma
–Intake of catecholamine precursors in patients taking
monoamine oxidase inhibitors
–Head injuries
–Severe burns or trauma
–Rebound hypertension after withdrawal of
antihypertensive drugs
Causes of Hypertensive Crises (cont.)
ƒ Severe to moderate hypertension
accompanying :
–Acute left ventricular failure
–Intracranial hemorrhage
–Dissecting aortic aneurysm
–Postoperative bleeding
–Severe epistaxis
Treatment of Hypertensive Crisis
in the Office
ƒ High flow O2
ƒ Call EMS
ƒ Consider placing IV / heplock
ƒ Consider IV narcotic or
benzodiazepine
ƒ Consider SL TNG to decrease BP
acutely (0.4 mg)
ƒ Recheck BP frequently till EMS arrives
Options for Office Treatment of
Hypertensive Emergency
ƒ Oral / SL Nifedipine 10 to 20 mg
ƒ Clonidine 0.1 mg to 0.2 mg PO
ƒ Labetolol 100 mg PO or 20 to 40 mg IV
ƒ + IV furosemide 20 to 80 mg
ƒ TNG ointment 1/2" to 1"
ƒ MgSO4 2 gms IV if eclamptic
ƒ Morphine 2 to 4 mg IV (if CHF)
Drug Induced Hypertensive Crisis
ƒ Cocaine
ƒ Amphetamines
ƒ Phencyclidine (PCP)
ƒ Diet pills
ƒ OTC sympathomimetics
ƒ MAO Inhibitors / Tyramine
 4.Antihypertensive Meds for
Eclampsia

ƒ Drugs of choice : Hydralazine, Labetolol

ƒ Inhibit uterine contractions : Diazoxide, Calcium
antagonists
ƒ Use only if refractory to other agents :
nitroprusside
ƒ Contraindicated : Trimethaphan (meconium
ileus), "Pure" beta blocker agents ( decreased
uterine blood flow), Diuretics (patient already
volume depleted)
ƒ Don't forget magnesium--------MgSO4
 Treatment of Drug Induced
Hypertensive Crisis

ƒ Labetalol : preferred
ƒ Nitroprusside
ƒ Nifedipine / Verapamil
ƒ Phentolamine
ƒ Since duration of HBP often brief, may not
need treatment
ƒ Note : Pure Beta blockers may cause increased
BP (from unopposed alpha effect)
 Medical Therapy in
5. Acute Myocardial Infarction
MONA + BAH
• Morphine (class I, level C)
• Analgesia
• Reduce pain/anxiety—decrease sympathetic tone,
systemic vascular resistance and oxygen demand
• Careful with hypotension, hypovolemia, respiratory
depression

• Oxygen (2-4 liters/minute) (class I, level C)

• Up to 70% of ACS patient demonstrate hypoxemia
• May limit ischemic myocardial damage by increasing
oxygen delivery/reduce ST elevation
• Nitroglycerin (class I, level B)
• Analgesia—titrate infusion to keep patient pain
free
• Dilates coronary vessels—increase blood flow
• Reduces systemic vascular resistance and
preload
• Careful with recent ED meds, hypotension,
bradycardia, tachycardia, RV infarction
• Aspirin (160-325mg chewed & swallowed) (class I, level A)
• Irreversible inhibition of platelet aggregation
• Stabilize plaque and arrest thrombus
• Reduce mortality in patients with STEMI
• Careful with active PUD, hypersensitivity,
bleeding disorders
• Beta-Blockers (class I, level A)
• 14% reduction in mortality risk at 7 days at 23% long
term mortality reduction in STEMI
• Approximate 13% reduction in risk of progression to MI
in patients with threatening or evolving MI symptoms
• Be aware of contraindications (CHF, Heart block,
Hypotension)
• Reassess for therapy as contraindications resolve

• ACE-Inhibitors / ARB (class I, level A)

• Start in patients with anterior MI, pulmonary
congestion, LVEF < 40% in absence of
contraindication/hypotension
• Start in first 24 hours
• ARB as substitute for patients unable to use ACE-I
• Heparin (class I, level C to class IIa, level C)
– LMWH or UFH (max 4000u bolus, 1000u/hr)
• Indirect inhibitor of thrombin
• less supporting evidence of benefit in era of reperfusion
• Adjunct to surgical revascularization and thrombolytic /
PCI reperfusion
• 24-48 hours of treatment
• Coordinate with PCI team (UFH preferred)
• Used in combo with aspirin and/or other platelet
inhibitors
• Changing from one to the other not recommended
 Additional medication therapy
• Clopidodrel (class I, level B)
• Irreversible inhibition of platelet aggregation
• Used in support of cath / PCI intervention or if
unable to take aspirin
• 3 to 12 month duration depending on scenario

• Glycoprotein IIb/IIIa inhibitors

(class IIa, level B)
• Inhibition of platelet aggregation at final common
pathway
• In support of PCI intervention as early as possible
prior to PCI
MANNITOL
Osmotic diuretic – for cerebral
edema  may inc ICP
 initial dose – 0.5-1g/kg IV of 25%
solution
Note: highly irritating to the veins
 forms crystals
9.Alcohol Withdrawal
(Delirium Tremens)
• Approximately 5% of patients withdrawing from
alcohol will experience delirium tremens
characterized by:

– Hallucinations
– Disorientation
– Tachycardia
– Hypertension
– Low grade fever
– Agitation
– Diaphoresis
 Treatment
• **Benzodiazepines-

• The preferred agents for treating the symptoms of

alcohol withdrawal syndrome.

• Diazepam and Chlordiazepoxide are long acting agents. The

long half life makes withdrawal symptoms and rebound from
the Benzos less likely to occur.
• Ex: Diazepam 5mg IV (2.5mg/min).
• If initial dose is not effective, repeat in 5-10minutes. If
the second dose is not effective, use 10mg for 3rd and 4th
doses every 5-10 minutes.
• If not effective, use 20mg for the 5th and subsequent
doses until sedation is achieved,. Use 5-20mg/hour as
needed to maintain light somnolence (5)
With appropriate treatment, mortality rate from DTs is <3%
 Alcohol withdrawal treatment
– Short acting benzos like lorazepam may be better
for pts who are elderly or have substantial liver
disease and prolonged sedation is a risk.

– Diazepam, Lorazepam may be administered

parenterally when oral dosing is impossible.

– “Fixed Dose” or “Loading dose” vs. “symptomatic”

therapy
• Fixed dose allows “stable” control of symptoms
followed by a 4-7 day taper
• Symptomatic- Pts use less benzodiazepines but must
have trained/available nurses to administer
 Choice of a BZD

 Long half-life (chlordiazepoxide, diazepam):

  Seizures: ~ 58%

  Distress (“smoother detox”)

Shorter half-life (lorazepam, oxazepam)

  Oversedation

 Safer in elderly / liver impairment

 Alcohol withdrawal treatment
 B-Blockers in conjunction with benzos to control persistent
HTN and tachycardia. There is no evidence these improve
outcome.

 Carbamazepine can be used to treat the seizures, this is done

more in Europe than in the US.

 Haloperidol can be used to treat agitation and hallucinations

 Nutrition support: Thiamine to avoid Wernicke-Korskoff, Mg
supplementation, folate if needed.

 Acamprosate, disulfiram appropriate for abstinence therapy

NOT withdrawal
 Carbamazepine and Valproate
• Effective in:
 Mild to moderate AW / protracted AW
 distress and faster return to work
 No abuse potential / alcohol interactions
 No toxicity in 7-day trials

• Limitations:
 Not better than BZDs
  Side effects
  Cost
 Limited data in AW seizures/delirium
 Nonpharmacological Treatment

• Quiet environment
• Nutrition and hydration:
 Oral thiamine (prevents Wernicke-Korsakoff) /
folic acid
 Oral fluids / electrolytes
• Orientation to reality
• Brief interventions / motivate to change
• Referral to AA / relapse prevention tx.
 ASTHMA
Symptoms and Signs
Clinical features of acute severe asthma in adults
include:
• Inability to complete sentences in one breath.
• Respiratory rate > 25 per minute.
• Tachycardia (heart rate > 110 per minute).
Clinical features of life threatening asthma in adults
include:
• Cyanosis or respiratory rate < 8 per minute.
• Bradycardia (heart rate < 50 per minute).
• Exhaustion, confusion, decreased conscious level.
Recommended Minimal Emergency
Drugs / Equipment for the Office
ƒ Oxygen masks / nasal prongs
ƒ Reliable O2 tank supply
ƒ Suction catheters : flexible and Yankauer
ƒ IV catheters : 20 g, 18 g (22 g if children treated)
ƒ 500 cc or 1000 cc bags of NS
ƒ IV tubing sets
ƒ Epinephrine 1 : 1000 vials (1 mg per cc)
Optional Meds for Office
Emergencies
ƒ Antihistamines amps
ƒ Alupent or albuterol solution for
aerosols or MDI's
ƒ Hydrocortisone 100 mg amps
ƒ Glucagon 1 mg amps