Neuromuscular and Ganglionic Blocking Agents

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thedewhub
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294979
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Neuromuscular and Ganglionic Blocking Agents
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2015-02-07 13:25:24
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Neuromuscular Ganglionic Blocking Agents
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Neuromuscular and Ganglionic Blocking Agents
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  1. Muscarinic agonist aka parasympathomimetic Systemic effects?
    • SLUDGE (salivation, lacrimation, urinary incont, diarrhea, GI cramps, emesis)
    • pupil constrict
    • broncho constrict
    • decrease hr and conduct
    • vasodilation
    • GI/GU- increased motility and secretion, bladder contract, sphincter relax- pee
    • Increased sweat  and saliva
  2. Muscarinic agonist aka parasympathomimetics
    • – muscarine is a true prototype, but bethanechol is a good example of one used clinically (used for urinary retention and delayed gastric emptying)
    • "bethanechol when you pee too much and dont poop at all- use bethanechol!"
  3. Muscarinic agonist contra
    • asthma- bronchoconstrict
    • Acid-peptic dx- increase gastric secretion
    • Coronary insuff- worsen bradycardia
  4. Pilocarpine
    • another muscarinic agonist
    • for dry mouth- promotes salivation
    • "pilocarpine - to start PAVLOVing"
  5. m1, m2, m3 ,m4, m5 excite or inhibit?
    • odds- excite
    • even- inhibit 
  6. Muscarinic antagonist aka sympathomimetics
    example?
    Systemic effects?
    • – "atropine- makes your heart sing"- blocks vagal slowing on SA node- increased HR
    • Scopalamine- 
    • Pupil Dilation
    • GI GU- plug up
    • Lung- decrease secretions- dry up
    • Tachy- dose dependent
    • Glands- block sweating and salivation
    • CNS (Scopalamine)- reduce parkinsonian tremor and altered vestibular function
  7. atropine intox? aka antimuscarinic poisoning
    aka- anticholinergic syndrome
    Clinical manifestations?
    Treatment?
    • mad as a hatter
    • blind as a bat
    • dry as a bone (mouth)
    • red as a beet (flushing)
    • hot as a furnace
    • use a muscarinic AGONIST- overcome muscarinic receptor blockade- Physostigmine "(antillirium)- fights atropine dilirium"
  8. tiotropium (spiriva)
    ipratropium
    for?
    which is better?
    • -COPD acts at m1,2,3- bronchodilation, BETTER
    • - COPD- nonselective for m1,2,3- potential for paradoxical bronchoconstriction
  9. Nicotinic agonist (remember cholinergic agonists are either nicotinic or muscarinic!)
    2 types of Nicotinic?
    • Direct– nicotine, succinycholine
    • Indirect- AChEsterase inhibitor
  10. ACh metabolism by AChE
    Process?
    Sites of action?
    • HYDROLYSIS!
    • -Anionic Site- binds ACh to enzyme
    • -Esteratic Site- hydrolysis breaks ester bond
  11. Anticholinesterases-
    3 major groups?
    Duration of action?
    Alcohols<carbamates<organophosphates
  12. Organophosphate
    Example
    • AntiCholinesterase inhibitor (irreversable- need new AChE)
    • Ex: echothiophate
  13. Carbamate?
    Example?
    • Anticholinesterase inhibitor (reversable) 
    • ex: Physostigmine- (reverse anticholinergic syndrome from atropine)
  14. Simple Alcohol?
    example
    • Competitive AntiCholinesterase Inhibitor- competes for ANIONIC site
    • Edrophonium
  15. Organophosphate poisoning treatment
    Symptoms of exposure
    • -Oxygen
    • -Atropine + Pralidoxime
    • -Benzos

    Same as Parasympathetic SLUDGE + bradycardia+ muscle fasciculations+CNS slurring
  16. Myasthenia Gravis
    what happens?
    Diagnosis?
    Treatment?
    Antibody made blocks ACh binding to receptor

    Dx- Edrophonium test, + test shows obvious muscle strength improvement for 5 min

    • Immunosupress Prednisone
    • Pyridostigmine
  17. Ganglionic blocker example –
    mecamylamine- noncompetitive blocker- autonomic NS paralysis
  18. DEPOLARIZING NMJ blocker
    – succinylcholine
  19. NON-depolarizing blocker
    – again, like muscarine, d-tubocurarine (or curare) is a prototype not used often clinically; but if you remember that these drugs end in “onium” and “urium” you should be ok
  20. Acetylcholinesterase inhibitor
    – simple alcohol – Edrophonium (note – this one ends in “onium” but is NOT an NMJ blocker!)
  21. Acetylcholinesterase inhibitor
    – carbamate – Neostigmine
  22. Acetylcholinesterase inhibitor
    – organophosphate – Echothiophate
  23. Alzheimers and Cholinergics
    -What do muscarinic blocking agents do?
    - ChAT levels and ACh?
    -# of nicotinic and Muscarinic receptors
    - induce memory loss

    -dramatic ChAT drop- reduced ACh output

    - reduced in alzheimers
  24. blood vessels- sympathetic or par tone?
    cholinergic or adrenergic?
    • - sympathetic
    • - adrenergic
  25. dominant tone at rest?
    parasympathetic
  26. sweat glands- sympathetic or para tone?cholinergic or adrenergic?
    • sympathetic tone
    • cholinergic
  27. Dominant tone?- para or sympat with addition of a muscarinic receptor agonist
    para- more motility observed
  28. Dominant tone?- para or sympat with addition of a muscarinic receptor anatagonist
    • sympathetic- para is blocked
    • less motility
  29. Dominant tone?- para or sympat with addition of a nicotinic receptor antagonist
    neither, both sympathetic and parasympathetic tone are blocked
  30. Dominant tone?- para or sympat with addition of a beta adrenergic receptor agonist
    • sympathetic tone is increased
    • motility is decreased
  31. Dominant tone?- para or sympat with addition of a beta adrenergic antagonist
    • parasympathetic- 
    • sym is blocked- greater motility and tone
  32. How can a nictinic receptor agonist act as a blocker?
    initial stimulation- after ion flow has occurred- unbinding of agonist has not occurred and therefore acts as a blocker
  33. nicotinic and muscarinic- ion or g protein?
    • nic- ion
    • musc- g protein
  34. nicotine effects
    • muscle- depolarization fasciculation
    • adrenal medulla- epi release- increase hr/bp
    • cns- exicte, convulsion, resp stim, coma
    • ganglia- depends on dom tone, secretion stim and n/v/d
  35. nicotinic receptor anatagonist aka ganglionic blockade effect on BV?
    hypotn
  36. nicotinic receptor anatagonist aka ganglionic blockade effect on sweat glands
    anhidrosis
  37. nicotinic receptor anatagonist aka ganglionic blockade effect on heart
    tachy
  38. nicotinic receptor anatagonist aka ganglionic blockade effect on pupillary fxn and lens
    mydriasis and blurred vision(cyclopegia)
  39. nicotinic receptor anatagonist aka ganglionic blockade effect on gut
    decreased tone and motility
  40. nicotinic receptor anatagonist aka ganglionic blockade effect on bladder
    urinary retentio
  41. nicotinic receptor anatagonist aka ganglionic blockade effect on salivary gland
    xerostomia
  42. ganglionic therapeutic use
    • control hemorrhage in surgery
    • severe htn
    • dissecting aortic aneurysm
    • autonomic reflexia- sc injury
  43. succinycholine
    • depolarizing blocker- binds to nicotinic receptors at motor end terminal
    • na and ca diffuse into cell and depolarizes this is phase I blockade
    • SUx is not metabolized by AChE-remains attached and channel stays open
    • new action potential cannot occur until repolarization- have paralyzation because contractions cannot occur- Phase II
    • sux is metabolized by palsma cholinesterase
  44. SUX contra
    causes hyperkalemia- worry in pts prone to this like burn victims

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