Section 5.2: MICA Pharmacology Flashcards
(140 cards)
1
Q
Adenosine – Presentation/s
A
- 6mg in 2mL glass ampoule
2
Q
Adenosine – Pharmacology
A
A naturally occurring purine nucleoside found in all body cells
Actions:
- Slows conduction through the A-V node, resulting in termination of re-entry circuit activity within or including the A-V nodal pathway
3
Q
Adenosine – Metabolism
A
- By adenosine deaminase in red blood cells and vascular endothelium
4
Q
Adenosine – Primary emergency indication/s
A
- AVNRT with adequate or inadequate perfusion but not deteriorating rapidly
- AVRT and associated Wolff-Parkinson-White (WPW) or other accessory tract SVT with adequate or inadequate perfusion but not deteriorating rapidly
5
Q
Adenosine – Contraindication/s
A
- Second or third degree A-V block (may produce prolonged sinus arrest / A-V blockade)
- Atrial fibrillation
- Atrial flutter
- Ventricular tachy-arrhythmias
- Known hypersensitivity
6
Q
Adenosine – Precaution/s
A
- Adenosine may provoke bronchospasm in the asthmatic Pt
- Adenosine is antagonized by methylxanthines (e.g. caffeine or theophyllines). The drug may not be effective in Pts with large caffeine intake or those on high doses of theophylline medication
7
Q
Adenosine – Route/s of administration
A
- IV
8
Q
Adenosine – Side effects
A
Usually brief and transitory:
- Transient arrhythmia (including asystole, bradycardia or ventricular ectopy) may be experienced following reversion
- Chest pain
- Dyspnoea
- Headache or dizziness
- Nausea
- Skin flushing
9
Q
Adenosine – Special notes
A
- Adenosine has a very short half life. It should be administered through an IV as close to the heart as practicable, such as the cubital fossa
10
Q
Adenosine – Onset, Peak & Duration times
A
IV effects:
- Onset: N/A
- Peak: N/A
- Duration: < 10 sec
11
Q
Amiodarone – Presentation/s
A
- 150mg in 3mL glass ampoule
12
Q
Amiodarone – Pharmacology
A
- Class III anti-arrhythmic agent
13
Q
Amiodarone – Metabolism
A
- By the liver
14
Q
Amiodarone – Primary emergency indication/s
A
- VF / pulseless VT refractory to cardioversion
- Sustained or recurrent VT
15
Q
Amiodarone – Contraindication/s
A
- VF / pulseless VT refractory to cardioversion:
* Nil of significance in this indication
2. VT (conscious):
- Inadequate perfusion
- Pregnancy
3. Tri-cyclic Antidepressant (TCA) Overdose
16
Q
Amiodarone – Precaution/s
A
- Following Fentanyl administration
17
Q
Amiodarone – Route/s of administration
A
- IV
18
Q
Amiodarone – Side effects
A
- Hypotension
- Bradycardia
19
Q
Amiodarone – Special notes
A
- Amiodarone is incompatible with saline. Glucose 5% must be used as dilutant when preparing an IV infusion.
- An IV infusion of Amiodarone may be required during inter-hospital transfer. This will be prescribed by the referring physician and will normally be at a dose of 10 – 20mg / kg run over 24hrs.
20
Q
Amiodarone – Onset, Peak & Duration times
A
IV effects (bolus):
- Onset: 2min
- Peak: 20min
- Duration: 2hr
21
Q
Atropine – Presentation/s
A
- 0.6mg in 1mL polyamp
- 1.2mg in 1mL polyamp
22
Q
Atropine – Pharmacology
A
An anti-cholinergic agent
Actions:
- Inhibits the actions of acetylcholine on post-ganglionic cholinergic nerves at the neuro-effector site, e.g. as a vagal blocker, and allows sympathetic effect to:
- Increase HR by increasing SA node firing rate
- Increase the conduction velocity through the A-V node
- Antidote to reverse the effects of cholinesterase inhibitors (e.g. organophosphate insecticides) at the post-ganglionic neuro-effector sites of cholinergic nerves to:
- Reduce the excessive salivary, sweat, GIT and bronchial secretions; and
- Relax smooth muscles
23
Q
Atropine – Metabolism
A
- By the liver. Excreted mainly by the kidneys.
24
Q
Atropine – Primary emergency indication/s
A
- Bradycardia with poor perfusion
- Organophosphate poisoning with excessive cholinergic effects
25
Atropine – Contraindication/s
* Officially, nil of significance in the above indications
* ? Known hypersensitivity to **Atropine** or its derivatives.
26
Atropine – Precaution/s
1. Atrial flutter
2. Atrial fibrillation
3. Do not increase HR above 100bpm except in children under 6 years
4. Glaucoma
27
Atropine – Route/s of administration
* IV
* ETT
28
Atropine – Side effects
* Tachycardia
* Palpitations
* Dry mouth
* Dilated pupils
* Visual blurring
* Retention of urine
* Confusion, restlessness (in large doses)
* Hot, dry skin (in large doses)
29
Atropine – Special notes
N/A
30
Atropine – Onset, Peak & Duration times
IV effects:
* Onset: \< 2min
* Peak: \< 5min
* Duration: 2 – 6hr
31
Dexamethasone – Presentation/s
* 8mg in 2mL glass vial
32
Dexamethasone – Pharmacology
A corticosteroid secreted by the adrenal cortex
Actions:
* Relieves inflammatory reactions
* Provides immunosuppression
33
Dexamethasone – Metabolism
* By the liver and other tissues. Excreted predominantly by the kidneys
34
Dexamethasone – Primary emergency indication/s
1. Bronchospasm associated with acute respiratory distress not responsive to nebulised Salbutamol
2. Anaphylaxis
3. Acute exacerbation of COPD
35
Dexamethasone – Contraindication/s
1. Known hypersensitivity
36
Dexamethasone – Precaution/s
1. Solutions which are not clear or are contaminated should be discarded
37
Dexamethasone – Route/s of administration
* IV
* IM
38
Dexamethasone – Side effects
* Nil of significance in the above indication
39
Dexamethasone – Special notes
* Does not contain an antimicrobial agent, therefore use the solution immediately and discard any residue
40
Dexamethasone – Onset, Peak & Duration times
IV effects:
* Onset: 30 – 60min
* Peak: 2hr
* Duration: 36 – 72hr
41
Dextrose 5% – Presentation/s
* 100mL infusion soft pack
42
Dextrose 5% – Pharmacology
An isotonic crystalloid solution
Composition:
* Sugar – 5% dextrose
* Water
Actions:
* Provides a small source of energy
* Supplies body water
43
Dextrose 5% – Metabolism
Dextrose:
* Broken down in most tissues
* Stored in the liver and muscle as glycogen
Water:
* Distributed throughout total body water, mainly in the extracellular fluid compartment
* Excreted by the kidneys
44
Dextrose 5% – Primary emergency indication/s
1. Vehicle for dilution and administration of IV emergency drugs
45
Dextrose 5% – Contraindication/s
* Nil of significance in the above indication
46
Dextrose 5% – Precaution/s
* Nil of significance in the above indication
47
Dextrose 5% – Route/s of administration
* IV infusion
48
Dextrose 5% – Side effects
* Nil of significance in the above indication
49
Dextrose 5% – Special notes
IV half life:
* Approximately 20 – 40min
50
Dextrose 5% – Onset, Peak & Duration times
* Onset: N/A
* Peak: N/A
* Duration: N/A
51
Enoxaparin (Clexane) – Presentation/s
* 100mg in 1mL pre-filled syringe with graduated markings (SC injection)
* 40mg in 0.4mL glass ampoule (IV bolus)
52
Enoxaparin (Clexane) – Pharmacology
* Binds to and accelerates the action of antithrombin III which inactivates clotting factors IIa (thrombin) and Xa, inhibiting the conversion of prothrombin to thrombin
53
Enoxaparin (Clexane) – Metabolism
* Metabolised by the liver
54
Enoxaparin (Clexane) – Primary emergency indication/s
1. Acute STEMI
55
Enoxaparin (Clexane) – Contraindication/s
1. Known allergy or hypersensitivity
2. Active bleeding (eg peptic ulcer, intracranial haemorrhage)
3. Bleeding disorders
4. Severe hepatic impairment / disease
5. Heparin-induced thrombocytopenia (HIT)
56
Enoxaparin (Clexane) – Precaution/s
1. Renal impairment
2. If Pt \> or = 75yo, omit the initial IV bolus dose and only administer 0.75mg / kg SC injection with a maximum 75mg SC
57
Enoxaparin (Clexane) – Route/s of administration
* Enoxaparin 30mg IV followed 15min later by 1mg / kg SC not exceeding 100mg SC
58
Enoxaparin (Clexane) – Side effects
* Bleeding
* Bruising
* Pain at injection site
* Hyperkalaemia
* Mild reversible thrombocytopenia
**Infrequent**
* Transient elevation of liver aminotransferases
* Severe thrombocytopenia
**Rare**
* Skin necrosis at injection site
* Osteoporosis with long term use
* Allergic reactions including urticaria and anaphylaxis
* Hypersensitivity reactions
59
Enoxaparin (Clexane) – Special notes
* STEMI – 12 lead ECG shows ST elevation \> or = 1mm in two contiguous limb leads (I, II, III, aVR, aVL, aVF) **or** ST elevation \> or = 2mm in two contiguous chest leads (V1, V2, V3, V4, V5, V6), new LBBB
60
Enoxaparin (Clexane) – Onset, Peak & Duration times
* Onset: Within 3hrs
* Peak: 3 – 6hrs
* Duration: \> or = 12hrs
61
Frusemide – Presentation/s
* 40mg in 4mL glass ampoule
62
Frusemide – Pharmacology
A diuretic
Actions:
* Causes venous dilatation and reduces venous return
* Promotes diuresis
63
Frusemide – Metabolism
* Excreted by the kidneys
64
Frusemide – Primary emergency indication/s
1. Acute LVF with SOB and audible fine crackles (bases, mid-zones or full field)
65
Frusemide – Contraindication/s
* Nil of significance in the above indication
66
Frusemide – Precaution/s
1. Hypotension
67
Frusemide – Route/s of administration
* IV
68
Frusemide – Side effects
* Hypotension
69
Frusemide – Special notes
* The effect of vasopressor drugs will often be reduced after Rx with **Frusemide**
70
Frusemide – Onset, Peak & Duration times
IV effects:
* Onset: 5min
* Peak: 20 – 60min
* Duration: 2 – 3hr
71
Ketamine – Presentation/s
* 200mg in 2mL vial
72
Ketamine – Pharmacology
A rapid acting dissociative anaesthetic agent (primarily an N-methyl-D-aspartate [NMDA] receptor antagonist)
Actions:
Produces a dissociative state characterised by:
* A trance-like state with eyes open but not responsive
* Nystagmus
* Profound analgesia
* Normal pharyngeal and laryngeal reflexes
* Normal or slightly enhanced skeletal muscle tone
* Occasionally a transient and minimal respiratory depression
73
Ketamine – Metabolism
* By the liver and excreted by the kidneys
74
Ketamine – Primary emergency indication/s
1. Rapid sequence intubation
2. Intubation facilitated by sedation
75
Ketamine – Contraindication/s
1. Known hypersensitivity
2. Severe hypertension (SBP \> 180mmHg)
76
Ketamine – Precaution/s
1. Any condition where significant elevation of BP would be hazardous:
* Hypertension
* CVA
* Recent AMI
* CCF
2. If being administered for analgesia, inject slowly over 1/60 to minimize risk of respiratory depression and hypertension
77
Ketamine – Route/s of administration
* IV
* IO
78
Ketamine – Side effects
Cardiovascular:
* Increase BP and HR
CNS:
* Respiratory depression or apnoea
* Emergent reactions (nightmares, restlessness, vivid dreams, confusion, hallucinations, irrational behaviour)
* Enhanced skeletal tone
* Nausea and vomiting
Ocular:
* Diplopia and nystagmus with slight increase in intraocular pressure
Other:
* Local pain at injection site
* Lacrimation
* Salivation
79
Ketamine – Special notes
N/A
80
Ketamine – Onset, Peak & Duration times
IV / IO effects:
* Onset: 30sec
* Peak: 12 – 25min
* Duration: N/A
81
Lignocaine 1% (IO Administration) – Presentation/s
* 50mg in 5mL amp (1%)
82
Lignocaine 1% (IO Administration) – Pharmacology
A local anaesthetic agent
Actions:
* Prevents initiation and transmission of nerve impulses (local anaesthesia)
83
Lignocaine 1% (IO Administration) – Metabolism
* By the liver (90%)
* Excreted unchanged by the kidneys (10%)
84
Lignocaine 1% (IO Administration) – Primary emergency indication/s
1. To reduce the pain of IO drug and fluid administration in the responsive Pt
85
Lignocaine 1% (IO Administration) – Contraindication/s
1. Known hypersensitivity
86
Lignocaine 1% (IO Administration) – Precaution/s
1. Hypotension and poor perfusion
2. Chronic LVF
3. Liver disease
87
Lignocaine 1% (IO Administration) – Route/s of administration
* IO
88
Lignocaine 1% (IO Administration) – Side effects
**CNS effects (common):**
* Drowsiness
* Disorientation
* Decreased hearing
* Blurred vision
* Change or slurring of speech
* Twitching and agitation
* Convulsions
**Cardiovascular effects (uncommon):**
* Hypotension
* Bradycardia
* Sinus arrest
* AV block
**Respiratory effects (uncommon):**
* Difficulty in breathing
* Respiratory arrest
89
Lignocaine 1% (IO Administration) – Special notes
N/A
90
Lignocaine 1% (IO Administration) – Onset, Peak & Duration times
IO effects:
* Onset: 1 – 4min
* Peak: 5 – 10min
* Duration: 20min
91
Oxytocin – Presentation/s
* 10 units (IU) in 1mL glass ampoule
92
Oxytocin – Pharmacology
A synthetic oxytocic
Action:
* Stimulates smooth muscle of the uterus producing contractions
93
Oxytocin – Metabolism
* By the liver; excreted by the kidneys
94
Oxytocin – Primary emergency indication/s
1. PPPH
95
Oxytocin – Contraindication/s
1. Previous hypersensitivity
2. Severe toxaemia (pre-eclampsia)
3. Cord prolapse
4. Exclude multiple pregnancy before drug administration
96
Oxytocin – Precaution/s
1. If given IV may cause transient hypotension
2. Concurrent use with **Methoxyflurane** may cause hypotension
97
Oxytocin – Route/s of administration
* IM
98
Oxytocin – Side effects
Uncommon via IM route:
* Tachycardia
* Bradycardia
* Nausea
99
Oxytocin – Special notes
Concomitant use with prostaglandins (**Misoprostol**) may potentiate uterotonic effect
## Footnote
**Must be stored between 2 – 8 °C**
100
Oxytocin – Onset, Peak & Duration times
IM effects:
* Onset: 2 – 4 min
* Peak: N/A
* Duration: 30 – 60min
101
Pancuronium – Presentation/s
* 4mg in 2mL polyamp
102
Pancuronium – Pharmacology
A non-depolarising neuromuscular blocking agent
Actions:
* Blocks transmission of impulses at the neuromuscular junction of striated muscles resulting in skeletal muscle paralysis
* Due to weak vagolytic action, a slight rise in HR and mean arterial pressure may be expected
103
Pancuronium – Metabolism
* By the kidneys; excreted mainly unchanged in the urine
104
Pancuronium – Primary emergency indication/s
1. To maintain skeletal muscle paralysis and allow mechanical ventilation in intubated Pts following IFS, RSI or during inter-hospital transfer of ventilated Pts.
105
Pancuronium – Contraindication/s
1. **Pancuronium** must not be given if continuous monitoring of Pt vital signs, including pulse oximetry and EtCO2 monitoring, is not available.
2. Status epilepticus
106
Pancuronium – Precaution/s
1. Ensure patency of IV access
2. Sedatives must always be administered prior to **Pancuronium**
3. ETT placement, adequacy of ventilation, Sp02, EtCO2, HR and BP must be continuously monitored
4. Pts with myasthenia gravis should be given much smaller doses and monitored carefully due to the potential of increased degree of neuromuscular block
5. Care should be exercised in Pts with renal impairment
107
Pancuronium – Route/s of administration
* IV
* IO
108
Pancuronium – Side effects
* Slight increase in HR
* Slight increase in mean arterial pressure
* Localised reaction at injection site (rare)
109
Pancuronium – Special notes
* Allergic reactions such as urticaria, laryngeal oedema, bronchospasm and anaphylactic shock have been reported.
* **Pancuronium** infusions required during inter-hospital transfers are to be prescribed and signed by the referring hospital medical officer. The initial dose is usually 0.1mg / kg.
110
Pancuronium – Onset, Peak & Duration times
IV effects:
* Onset: 2 – 3min
* Peak: 8 – 10min
* Duration: 35 – 45min
111
Sodium Bicarbonate 8.4% – Presentation/s
* 50mL prepared syringe
* 100mL glass bottle
112
Sodium Bicarbonate 8.4% – Pharmacology
A hypertonic crystalloid solution
Composition:
* Contains sodium and bicarbonate ions in a solution of high pH
Action:
* Raises pH
113
Sodium Bicarbonate 8.4% – Metabolism
* Sodium: Excreted by the kidneys
* Bicarbonate: Excreted by the kidneys as bicarbonate ion and by the lungs as CO2
114
Sodium Bicarbonate 8.4% – Primary emergency indication/s
1. Cardiac arrest, after 15min of AV CPR
2. **Symptomatic** TCA OD
115
Sodium Bicarbonate 8.4% – Contraindication/s
1. Hypothermia \< 30°C
116
Sodium Bicarbonate 8.4% – Precaution/s
1. Administration of **Sodium Bicarbonate 8.4%** must be accompanied by effective ventilation and ECC if required
2. Since **Sodium Bicarbonate 8.4%** causes tissue necrosis, care must be taken to avoid leakage of the drug into the tissues
3. Because of the high pH of this solution, do not mix or flush any other drug or solution with **Sodium Bicarbonate 8.4%**
117
Sodium Bicarbonate 8.4% – Route/s of administration
* IV
118
Sodium Bicarbonate 8.4% – Side effects
* Sodium overload may provoke pulmonary oedema
* Excessive doses of **Sodium Bicarbonate 8.4%**, especially without adequate ventilation and circulation, may cause an intracellular acidosis
119
Sodium Bicarbonate 8.4% – Special notes
N/A
120
Sodium Bicarbonate 8.4% – Onset, Peak & Duration times
IV effects:
* Onset: 1 – 2min
* Peak: N/A
* Duration: Depends on cause and Pt’s perfusion
121
Suxamethonium – Presentation/s
* 100mg in 2mL polyamp
122
Suxamethonium – Pharmacology
Depolarising neuromuscular blocking agent
Actions:
* Short acting muscular relaxant
123
Suxamethonium – Metabolism
* Pseudo-cholinesterase in plasma
124
Suxamethonium – Primary emergency indication/s
1. Complete muscle relaxation to allow endotracheal intubation
125
Suxamethonium – Contraindication/s
1. Known hypersensitivity
2. Known history of Suxamethonium apnoea
3. Known history of malignant hyperthermia
4. Upper airway obstruction
5. Severe respiratory distress
6. Penetrating eye injury
7. Burns \> 24hr post injury
8. Ruptured AAA
9. Organophosphate poisoning
10. ECG signs of hyperkalaemia in conditions such as muscle necrosis and renal failure
126
Suxamethonium – Precaution/s
1. Elderly Pts
2. Liver disease
3. Crush injuries
4. Pts who have not fasted
5. Airway trauma
127
Suxamethonium – Route/s of administration
* IV
* IO
128
Suxamethonium – Side effects
* Muscular fasciculation
* Increased intraocular pressure
* Increased intragastric pressure
* Elevated serum potassium levels
129
Suxamethonium – Special notes
* Sedation is required prior to use
* **Atropine** 600mcg should be administered prior to **Suxamethonium** administration in adult Pts with a HR \< 60
* **Atropine** 20mcg / kg should be administered prior to **Suxamethonium** administration in children
* A second dose of **Suxamethonium** usually causes profound bradycardia
* Refrigeration of **Suxamethonium** is required – requires weekly rotation or disposal when not refrigerated
* Usual dosage:
* Adults: 1.5mg / kg IV (max. dose 150mg)
130
Suxamethonium – Onset, Peak & Duration times
IV effects:
* Onset: 20 – 40sec
* Peak: 60sec
* Duration: 4 – 6min
131
Tenecteplase (Metalyse) – Presentation/s
* 50mg in glass vial with weight marked and pre-filled syringe containing water for IV administration (must reconstitute all drug then discard unwanted amount according to weight)
132
Tenecteplase (Metalyse) – Pharmacology
* Fibrinolytic, a modified form of tissue plasminogen activator (tPA) that binds to fibrin and converts plasminogen to plasmin
133
Tenecteplase (Metalyse) – Metabolism
* By the liver
134
Tenecteplase (Metalyse) – Primary emergency indication/s
1. Acute STEMI
135
Tenecteplase (Metalyse) – Contraindication/s (Exclusion Criteria)
1. Blood pressure Systolic \> 180mmHg; or Diastolic \> or = 110mmHg
2. Known allergy or hypersensitivity to Tenecteplase or Gentamicin
3. Anticoagulant therapy eg. Warfarin, Heparin, Dabigatran, Rivaroxaban, Apixaban
4. Glycoprotein IIb / IIIa inhibitors eg. Abciximab, Eptifibatide, Tirofiban
5. Active bleeding or bleeding tendency (excluding menses)
6. GI bleed within last 1/12
7. Active peptic ulcer
8. Acute pancreatitis
9. Suspected aortic dissection
10. Non compressible vascular puncture
11. Recent major surgery (\< 3/52)
12. Traumatic or prolonged (\>10min) CPR
13. Acute pericarditis
14. Subacute bacterial endocarditis
15. History of CNS damage eg neoplasm, aneurysm, spinal surgery
16. New neurological symptoms
17. Significant closed head or facial trauma in past 3/12
136
Tenecteplase (Metalyse) – Precaution/s (Relative contraindications)
1. Age \> or = 75 years
2. Low body weight
3. Renal impairment
4. Dementia
5. History of stroke or TIA
6. Diabetes
7. Heart failure
8. Tachycardia
9. Pregnancy
10. Within 1/52 post-partum
11. Anaemia
12. Advanced liver disease
13. Blood pressure between 160 – 180mmHg systolic
14. History of bleeding or known prolonged INR
15. Peripheral vascular disease
16. Administration of Enoxaparin 48 hours prior
17. Recent invasive procedures associated with bleeding such as femoral artery puncture; right heart catheterisation
137
Tenecteplase (Metalyse) – Route/s of administration
* IV, using vial adapter on pre-prepared syringe, as single bolus over 10 seconds
138
Tenecteplase (Metalyse) – Side effects
* Bleeding – including injection sites, ICH, internal bleeding
* Transient hypotension
**Infrequent:**
* Allergic reactions including fever, chills, rash, nausea, headache, bronchospasm, vasculitis, nephritis and anaphylaxis
**Rare:**
* Cholesterol embolism
139
Tenecteplase (Metalyse) – Special notes
* STEMI – 12 lead ECG shows ST Elevation \> or = 1mm in two contiguous limb leads (I, II, III, aVR, aVL, aVF) or ST Elevation \> or = 2mm in two contiguous chest leads (V1, V2, V3, V4, V5, V6), new LBBB
* Weight optimised dosing improves efficacy and safety outcomes in drugs with narrow therapeutic index eg. Fibrinolytics
* Other drugs which affect the clotting process may increase risk of bleeding associated with **Tenecteplase**
140
Tenecteplase (Metalyse) – Onset, Peak & Duration times
IV effects:
* Onset: N/A
* Peak: N/A
* Duration: N/A
