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- Non-narcotic analgesic
- Tx of mild pain
- Reduce fever >38°C (AHS)
Acetaminophen Mechanisms of Action
- 1. Acts of hypothalamic centre to produce vasodilation and block prostaglandin synthesis in CNS with minimal effects on peripheral prostaglansin, explaining it's lack of anti-inflammatory effects compared to ASA.
- 2. Nonsalicylate analgesic-antipyretic
- 3. 90-95% metabolized in liver with glucuronic acis, sulfuric acid and cystein.
- 4. Inhibits cyclooxygenase which is responsible for formation of prostaglandin.
Acetaminophen Adverse Effects
Virtually free of severe toxicity or side effects when used as directed.
- 1. Chronic alcohol impairs liver function - Acetaminophen hepatotoxicity
- 2. Barbiturates enhance metabolism
- 3. Caution in pts <3y/o
- 4. Crosses placenta, safe for short term use.
- Acetaminophen-induced liver disease or acute liver disease.
- Adult 975mg PO (AHS)
- 500-1000mg q4-6hrs, not to exceed 4g/24hrs.
- Pediatric 15mg/kg PO (AHS)
- 10-15mg/kg q4-6hrs, max 75mg/kg/24hrs or 5 doses
Acetaminophen Drug Interactions
- Warfarin: Potentiates anticoagulant effect.
- Cholestyramine: Reduces absorption of acetaminophen
- Barbiturates: Enhances metabolism of acetaminophen - can increase clearance, diminish therapeutic effect and increase hepatotoxicity.
Acetaminophen Toxic Levels and S/S seen in (time frame)
> or equal to 150mg/kg in both peds and adults or >7.5g in adults.
Effects seen in 24-36hrs - severe hepatic damage
Prevent hepatotoxicity in acetaminophen OD
Acetylcysteine Mechanism of Action
- 1. Since hepatotoxicity occurs when glutathione (binds of toxic metabolites of acetaminophen until excreted) stores are depleted in acetaminophen OD, acetylcysteine is thought to provide cysteine for glutathione synthesis and acts as an alternate substrate to conjugate with toxic metabolites of acetaminophen.
- 2. Lowers mucous viscosity (cystic fibrosis, COPD, pneumonia...) and increases pH.
- 1. May induce bronchospasm in asthmatics
- 2. Pts must be able to cough to clear secretions.
Acetylcysteine Side Effects
- 1. Bronchospasm
- 2. Chest tightness
- 3. Rhinorrhea
- 4. Fever
- 5. Clammy skin
- 6. N/V
- 7. Fatigue
- 8. Tachycardia
- 9. Hypo/hypertension
- 10. Stomatitis
Administer 3 doses, same for peds and adults:
- 1. 150mg/kg in 25ml NS or D5W over 15min.
- 2. 50mg/kg in 500ml over 4hrs.
- 3. 100mg/kg in 1000ml over 16hrs.
or PO: 140mg/kg loading dose followed by 70mg/kg q4hrs for 17 doses.
Acetylcysteine Trade names
Musomyst, Musolysion, Parvolex, Bronkyl, fluimuscil, Mucosil
Acetylcysteine Supplied Forms
- 20% solution - 200mg/ml
- 10% solution - 100mg/ml
- 1. Most effective when used 4-8hrs post exposure, but can be used up to 24hrs post exposure.
- 2. Does not reverse hepatotoxicity, only prevents it.
- 3. Can interfere with lab testing, draw blood first.
Acetylcysteine Drug Interactions
Nitrates: Potentiates vasodilation effects.
Acetylsalicylic Acid Classifications
- 1. Analgesic
- 2. Anti-inflammatory
- 3. Antipyretic
- 4. Platelet Aggregation Inhibitor
Acetylsalicylic Acid Mechanisms of Action
- 1. Interferes with the production of prostaglandin by inactivating cyclooxygenase (COX) which is an enzyme involved in early stages of inflammatory cascade. It mostly acts in the peripheral body, with similar minimal activity in the CNS, which is why it is a better anti-inflammatory agent than acetaminophen.
- 2.Lowers body temperature mainly by inhibiting prostaglandin E1 synthesis in the brain. Heat production is not affected, however dissipation is enhanced via increased blood flow through the skin and sweating.
- 3. Prevents thrombaxane A2 synthesis by acetylating COX which prevents platelets froms adhering together.
Acetylsalicylic Acid Indications
- 1. ACS
- 2. Relief of mild pain, fever, and inflammation
Acetylsalicylic Acid Contraindications
- 1. Hypersensitivity
- 2. Active GI Bleed
- 3. Asthma (w/ PmHx of bronchospasm with ASA)
- 4. Bleeding Disorders
Acetylsalicylic Acid Side Effects
- GI bleed/upset
Acetylsalicylic Acid Dosing
Analgesia and fever:
- ACS: 160-325mg PO
- 300mg PR
- Analgesia and fever: 325-650mg q4-6hrs
- Inflammation: 2.4 - 3.6g/day divided up. 60-90mg/kg in peds.
Acetylsalicylic Acid Drug Interactions
- Anticoagulants: Increases chances of GI bleed and has synergistic effect.Lithium: Increases serum levels of lithium.
- Digoxin: Increases serum levels of digoxin.
- Antacids: May reduce serum levels of ASA by decreasing absorption.
- Anti-inflammatories: Increases both drugs serum levels and side effects.
Acetylsalicylic Acid Toxicity levels/OD signs and symptoms
Mild-moderate: 150-300mg/kg - tinnitus, tachypnea*, hyperpyrexia, diaphoresis, lethargy, confusion.
Severe: 300mg/kg - increased vascular permeability resulting in pulmonary and cerebral edema. Seizures, coma.
Antidote therapy is not available, Tx is aimed at enhancing elimination.
Tachypnea* in early stages can result in respiratory alkalosis, forcing kidneys to try and compensate with HCO3 elimination and H+ retention, causing a more profound metabolic acidosis later.
Hyperglycemia followed by hypoglycaemia - multiple BGLs required. Cerebral glucose levels can decrease before peripheral levels.
Renal excretion is enhanced by alkaline diuresis - sodium bicarb with D5W solution. Potassium supplementation is often requires.
Acetylsalicylic Acid Notes
- 1. Can cause Reye's syndrome in pediatrics with chicken pox.
- 2. Mostly absorbed in stomach.
Activated Charcoal Classification
Activated Charcoal Mechanism of Action
- 1. Adsorbs certain chemicals and prevents their absorption from the GI tract.
- 2. SDAC: Forms effective barrier betweens GI mucosa and any remaining particulate material.
- 3. MDAC: Creates and maintains a concentration gradient across the GI wall and facilitates passive diffusion of toxic substances from blood stream into the GI tract where it is then adsorbed and excreted.
- 4. Especially effective in binding to ASA, amphetamines, strychnine, phenytoin, phenobarbital.
- 5. Alcohols, strong acids and alkalis, lithium, magnesium, potassium, heavy metals, and petroleum distillates do not adsorb well to charcoal.
Activated Charcoal Indications
Adsorption of ingested poisons when vomiting is contraindicated and/or following gastric lavage.
Activated Charcoal Contraindications
- 1. Unprotected Airways
- 2. Corrosive ingestion as it could affect visualization of endoscopiy.
- 3. GI hemorrhage or perforation
Activated Charcoal Side Effects
- Tarry Stool
Activated Charcoal Dosing
Should be suspended in water, not sorbitol.
- Adults: SDAC (single dose) 25-100g
- MDAC (multiple dose) following SDAC and then at least 12.6g qhr until pt recovers
Pediatrics: SDAC 0.5-1g/kg, max 50g MDAC following SDAC and then 1-2g q2-6hrs
Activated Charcoal Drug Interactions
Leflunomide: Charcoal will decrease serum levels of the active metabolites.
Activated Charcoal Notes
- 1. Not absorbed by the body.
- 2. Effectiveness is highest immediately after ingestion, but can be effective for up to 2 hrs depending if drug absorption is delayed.
Adenosine Mechanisms of Action
- 1. Slows AV nodal conduction
- 2. Interrupts reentry pathways through AV node restoring NSR in pts with PSVT.
- 3. Not effective in A-flutter/fib, VT although transient AV nodal block helps Dx atrial activity.
- 4. Potent vasodilator, but since half life is <10sec, hemodynamic changes are not usually seen
- 5. Metabolized via erythrocytes so renal or hepatic insufficiency does not affect activity.
- 1. PSVT
- 2. Orthodromic WPW (AVRT)
- 3. AVNRT
- 4. Wide complex Tachycardias in pediatrics.
- 1. Torsades/ polymorphic VT
- 2. Antidromic WPW
- 3. 2nd or 3rd degree heart block
- 4. Sick Sinus Syndrome
- 5. Hypersensitivity
- 6. Symptomatic Bradycardia
- 7. A-fib/flutter
- 8. Bronchospasm/severe asmtha - AHS
- 9. Pt taking carbamazepine or dipyridamole - AHS (reduce dose)
Adenosine Side Effects
- 1. Severe Bronchospasm
- 2. Facial Flushing (vasodilation effects)
- 3. H/A
- 4. Dizziness
- 5. SOB
- 6. Nausea
- 7. CP
- 8. Arrhythmias
- Adults: 1st dose 6mg. (20ml rapid flush)
- 2nd dose 12mg if rhythm does not convert.
- AHS - 12mg as first dose
- Peds: 0.1mg/kg max 6mg first dose.
- Second dose 0.2mg/kg max 12mg. Each with 10ml rapid flush.
- 1. Asthma, COPD
- 2. Dysrhythmias may be seen during conversion.
Adenosine Drug Interactions
- Dipyridamole: Can potentiate effects of adenosine, therefore lower doses are given.
- Carbamazepine: Increases degree and chances of heart block.
- Methylxanthines: Anagonize effects of adenosine, so higher doses are needed.
- Digoxin, verapamil: May be associated with VF.
- 1. Fibrinolytic
- 2. Thombolytic
Alteplase Mechanisms of Action
- 1. Binds to fibrin in a thrombus and converts the entrapped plasminogen to plasmin, initiating local fibrinolysis with minimal systemic effects.
- 2. 20-30% decrease in circulating fibrinogen.
- 1. Acute Ischemic Stroke
- 2. Acute MI
- 1. Symptom onset greater than 4hrs.
- 2. Evidence of intracranial hemorrhage.
- 3. Recent intracranial or intraspinal surgery, serious head trauma or previous stroke within 3 months.
- 4. Hx of intracranial hemorrhage.
- 5. Uncontrolled HTN at time of Tx.
- 6. Aggressive Tx required to reduce BP to specified limits.
- 7. Seizure at onset of stroke.
- 8. Active internal bleeding.
- 9. Intracranial neoplasm, arteriovenous malformation, or aneurysm.
- 10. Major surgery within 14 days.
- 11. GI or urinary tract hemorrhage within 21 days.
- 12. Arterial puncture at a non-compressible site within 7 days.
- 13. BGL <3 or >22mmol/LMI within 3 months and/or clinical presentation associated with post MI pericarditis.
- 14. Currently on anticoagulants with INR > 1.7 or a prothrombin time (PT) > 15sec
- 15. Heparin administration within 48hrs and elevated aPTT at presentation.
- 16. Platelet count < 100 000mm3
- 17. Hypersensitivity
Alteplase Side Effects
- 1. Bleeding
- 2. Allergic/anaphylactoid reaction
- 3. Fever
- 4. N/V
- 5. Reperfusion arrhythmias
0.9mg/kg max 90mg. 10% of dose as bolus and then the remaining over 60min.
- 1. Bronchodilator unrelated to beta agonists.
- 2. Methylxanthine
- 3. Xanthine
Aminophylline Mechanisms of Action
- 1. Exact Mech unknown
- 2.Relaxes smooth muscles without acting on adrenergic receptors
- 3. Stimulates resp. center in medulla.
- 4. Mild diuretic properties, increases CO and HR
- 5. Increases diaphragmatic contractility.
- 6. Complex of theophylline and dissociates into theophylline.
- 1. Bronchospasm with asthma, COPD - can be useful in situations where sympathomimetics are not effective.
- 2. CHF, pulmonary edema due to positive chrono/inotropic effects.
- 1. Hypersensitivity
- 2. Uncontrolled arrythmias
- 3. Symptomatic CAD
- 4. Hypotension
Aminophylline Side Effects
- 6mg/kg in 100ml over 20-30min.
- Slow infusion decreased risk of arrythmias
Aminophylline Drug Interactions
- Adenosine: Antagonizes adenosine effects.
- Benzodiazepines: Causes decreased sedative effects of benzos.
- Theophylline: Pt on chronic theophylline therapy should not receive until serum levels have been tested.
- Zafirlukast: Xanthines decrease serum levels of zafirlukast.
- 1. Narrow Therapeutic Index
- 2. Pediatrics are sensitive to xanthines
- 3. Absorption unpredictable
- 4. Rapid IV injections in pts with pronounced myocardial injury can result in sever hypotension or cardiac arrest.
Aminophylline OD Sign/Symptoms and Tx
Especially common in pediatrics.
Seizures, death, hyperreflexia, hallucinations, arrhythmias, marked hypotension.
Seizures may be difficult to control and IV benzos are used. May need to progress to barbiturates or propofol. Avoid phenytoin.
Class III antiarrythmic (Potassium channel blocker)
amiodarone mechanisms of action
- 1. considered class III but has characteristics of all 4 class.
- 2. Prolongs action potential duration and refractory period by blocking K channels.
- 3. Also was alpha blocking effects resulting in vasodilation.
- 1. Pulseless VT
- 2. V-Fib
- 3. VT with a pulse - re-entry pathways
- 4. A-fib (or A-flutter) with RVR for rate control
- 1. Severe sinus node dysfunction resulting in marked sinus brad.
- 2. 2nd or 3rd degree AV blocks unless pacemaker present
- 3. Symptomatic bradycardia
- 4. Hypersensitivity to iodine or amiodarone.
- 5. Cardiogenic shock/ cardiovascular colllapse (due to alpha blocking properties)
- 6. Thyroid dysfunction
- 7. Acute hepatitis
- 8. Interstitial pulmonary disease
- 9. Pt's predisposed to intracranial HTN
Amiodarone Side Effects
- 1. Hypotension
- 2. Bradycardia
- 3. Prolonged QTc, PR and QT intervals.
- 4. AV block
- 5. Increased ventricular beats
- 6. Pulmonary toxicity - cough, dyspnea, pleuritic pain.
- 7. Tremors
- 8. N/V
Peds: 5mg/kg, may repeat twice.
- Adults: VF/pulselss VT: initial dose of 00mg, floowed by 150mg in needed.
- VT with a pulse: 150mg in 250 D5W over 10min. Can be followed by 1mg/min for 6hrs, decreased to 0.5mg/min for 18hrs. Max 2.2g/24hrs.
Amiodarone Drug Interations
- Warfarin: Warfarin can be potentiated, increased PT by 100% after 3-4 days.
- Digoxin: Can cause digoxin toxicity.
- procainamide: Increases procainamide plasma concentrations. (reduce p. dose by 1/3)
- quinidine: Increases quinidine serum concentrations. (reduce q. dose by 1/3)
- phenytoin: Increases phenytoin serum concentrations and phenytoin decreases amiodarone levels.
- B-Blocker and Ca+ Channel blockers: Increases risk of blocks, bradys and sinus arrest.
- 1. Very long half life - up to 10 days IV and 100 days PO.
- 2. Distributed and stored extensively in adipose tissue before therapeutic effects occur.
- 3. Can cause pulmonary fibrosis, neuropathy, hepatotoxicity, corneal deposits, optic neuritis, blue-grey skin discolouration, and hypo/hyperthyroidism.
- 1. Selective Beta Blocker
- 2. Class II antiarrhythmic
Atenolol Mechanisms of Action
1. Cardioselective drug that blocks B1 receptors causing negative chrono and inotropic effects, lowers BP and myocardial O2 demand.
- 1. Stable, narrow tachys if not converted with adenosine.
- 2. Control V rate in A-fib/flutter
- 3. Certain forms of polymorphic VT
- 1. Bradycardia, 2-3rd° block, Sick sinus syndrome
- 2. Decompensated CHF
- 3. RV failure due to pulmonary HTN
- 4. Hyoptension
- 5. Hypersensitivity.
Atenolol Side Effects
- 1. Bradycardia
- 2. Heart Blocks
- 3. Hypotension
- 4. CHF
- 5. Bronchospasm (more with non-selective)
- 6. Lethargy and weakness.
5mg IV over 5min q 10min prn, may repeat once
Atenolol Drug Interactions
CCB: may result in severe hypotension, bradycardia and cardiac failure.
- Vagal Blocker
Atropine Mechanisms of Action
- 1. Binds to and blocks muscarinic receptors preventing acetylcholine from binding to those sites.
- 2. Great inhibitory effects on bronchial tissue and secretion of saliva and sweat.
- 1. Symptomatic bradycardia
- 2. AV blocks at nodal level
- 3. Preintubation, especially in pediatrics
- 4. Organophosphate poisoning
- 1. Hypothermic bradycardia
- 2. Hypersensitivity.
Atropine Side Effects
- 1. Tachycardia
- 2. Blurred Vision
- 3. Dry mouth
- 4. Dilated pupils
- 5. Confusion
- 6. Use in caution in pt with CAD due to increased myocardial demand.
- Pediatric: 0.02mg/kg min 0.1mg max 0.5mg, q3-5min prn may repeat once to max of 0.04mg/kg or 1mg, whichever is less.
Adult: 0.5mg q3-5min, max 3mg or 0.04mg/kg (3mg=75kg)
- Organophosphate Poisoning:
- Pediatrics: 0.05mg/kg q5min until reversal of SLUDGEM
Adults: 2mg q5min until reversal of SLUDGEM
1. Transplanted hearts will not respond due to denervation.
benztropine (Cogentin) Classifications
- Anticholingergic (antimuscarinic)
benztropine (Cogentin) Mechanisms or Action
1. Blocks cholinergic transmission, thus helping to correct the imbalance or dopamine/acetylcholine ratio (Parkinson's has low levels of dopamine). Therefore it acts similarly to augmentation of dopaminergic transmission.
benztropine (Cogentin) Indications
- 1. Acute dystonic reactions
- 2. All forms of Parkinson's
benztropine (Cogentin) Contraindications
- 1. Glaucoma
- 2. Hypersensitivity
- 3. Prostatic hyperplasia
- 4. Pyloric Stenosis
- 5. Myasthenia Gravis
benztropine (Cogentin) Side effects
- 1. Dry mouth
- 2. Tachycardia
- 3. Blurred vision
- 4. Confusion
- 5. Mydriasis
benztropine (Cogentin) dosing
Adults: 1-4mg IV/IM max 6mg/day. 2mg generally relieves symptoms
Calcium Chloride Classification
Calcium Chloride Mechanisms of Action
- 1. Positive inotropic effects
- 2. Enhances ventricular automaticity
- 3. Stabilizes myocardial contractility in hyperkalemia (>6mEq/L) by reducing the threshold potential of cardiac myocytes, thereby restoring the normal gradient with the resting membrane potential, and reverses ECG changes without changing serum K levels.
Calcium Chloride Indications
- 1. CCB OD
- 2. Cardiac arrest suspicious of electrolyte imbalances/prolonged arrest
- 3. Hyperkalemia
- 4. Mag Sulfate OD/Hypermagnesia
- 5. Hypocalcemia
- 6. BB OD refractory to glucagon, atropine, pacing and dopamine.
Calcium Chloride Contraindications
- 1. Digitalis Toxicity (increases arrhythmia risk)
- 2. Hypercalcemia
Calcium Chloride Side Effects
- 1. Bradycardia
- 2. Syncope
- 3. Arrhythmias
- 4. N/V
- 5. Cardiac arrest
Calcium Chloride Notes
- 1. Extravasation causes tissue necrosis
- 2. Can cause arterial vasospasm - caution with CAD and CVD.
- 3. Forms precipitate when in contact with sodium bicarb.
Calcium Chloride Dosing
- Cardiac Arrest:
- Adult: 1g SIVP/IO
- Adult/Ped: 20mg/kg max 1g over 5 min q 5min, max 40mg/kg or 2g.
- CCB OD:
- Adult: 500mg in 50ml NS over 10min q 10min max 1g.
- Peds: 20mg/kg in 50ml NS over 30min
cefazolin (Ancef) Classification
Cefazolin (Ancef) Mechanisms of Action
Inhibits bacterial cell wall synthesis, causing cell death.
Cefazolin (Ancef) Indications
- 1. Open Fractures
- 2. Wide variety of bacterial infections.
Cefazolin (Ancef) Contraindications
1. Hypersensitivity to cephalosporin antibiotics
Cefazolin (Ancef) Precautions
- 1. Pregnancy
- 2. Hepatic Insufficiency
- 3. Renal Insufficiency
- 4. Allergy to Penicillin
- 5. GI disease
Cefazolin (Ancef) Side Effects
- 1. GI upset
- 2. Anaphylaxis
- 3. Seizures in OD situations
Cefazolin (Ancef) Dosing
Adult: 1g over 5-15min q6-8hrs, max 12g/day
Ped: 25mg/kg over 5-15min q 6-8hrs. max 6g/day
Chlorpromazine Mechanisms of Action
- 1. Moderate-weakly binds to dopamine D2 receptors in mesolimbic system of brain
- 2. Blocks alpha adrenergic receptors and histamine receptors.
- 1. Acute psychosis
- 2. Aggresive/agitated behaviour
- 3. Prevent or treat N/V
- 1. Comatose
- 2. Presence of sedatives
- 3. Presence of hallucinogens of PCP-like compounds
- 1. Parkinsons
- 2. Seizure disorders
- 3. Elderly
Chlorpromazine Side Effects
- 1. EPS
- 2. Seizures
- 3. Hypotension
- 4. Physical and mental impairment
- 5. Drowsiness
- 6. Anticholinergic Effects
Adult: 25-100mg IM
Ped: 0.5mg/kg IM
Chlorpromazine Trade Names
Histamine H2 antagonist
Cimetidine Mechanisms of Action
- 1. Competitively blocks/binds to H2 receptors in gastric parietal cells (responsible to HCl production) reducing the secretion of gastric acid. (Gastric acid is secretion is stimulated by Aceylcholine, histamine and gastrin.)
- 2. Fully reversible
- 1. Treating peptic ulcers - duodenal or gastric.
- 2. Treating acute stress ulcers.
- 3. GERD
- 4. Management of upper GI hemorrhage where inhibition of gastric acid secretion is beneficial
Cimetidine Side Effects
- Mostly well tolerated.
- Rare side effects include cardiovascular effects, interstitial nephritis, erectile dysfunction, dermatologic reactions and confusion.
Cimetidine Side Effects
Impairs metabolism of warfarin, phenytoin diazepame, quinidine, carbamazepine, theophylline, imipramine.
Adult: 300mg in 50-100ml NS or D5W over 15min q6hrs, max 2400mg/day.
Platelet aggregate inhibitor
Clopidogrel Mechanisms of Action
- 1. Inhibits platelet aggregation by binding to ADP receptors on the surface of platelets (which blocks activation of GP IIb/IIIa receptors required for platelets to bind to fibrinogen and to each other).
- 2. Binds irreversibly, therefore platelets are affected for their lifespan.
- 1. Hypersensitivity
- 2. Bleeding disorder
- 3. Ulcer
Clopidogrel Side Effects
- 1. Bleeding (no antidote)
- 2. Fever
- 3. Allergic reaction
- 4. Myalgias (muscle pain)
- 5. Rash
Recent MI, CVA, or PVD:
ACS: 300mg PO followed by 75mg once a day, usually in combo with ASA.
STEMi: 75mg once a day in combo with ASA. Can be given with or without the 300mg loading dose.
Recent MI, CVA or PVD: 75mg every day
Codeine Mechanisms of Action
1. Metabolized (by CYP450 2D6 enzyme) into morphine and binds to various opioid receptors in CNS, spinal cord and GI tract to produce analgesia.
2. Acts as an anti-tussive
Mild - moderate pain
- 1. Hypersensitivity
- 2. Resp depression
- 3. Hypotension
- 4. Acute exacerbation of COPD or Asthma
- 5. MAOIs within 14 days
- 6. Caution in pt with renal dysfunction
Codeine Side Effects
- 1. Hypotension
- 2. Sedation
- 3. Constipation
- 4. Urinary retention
- 5. N/V
- 6. Myosis
- 7. Resp depression
Adult: 15-60mg PO/IM/SC q 4hrs
Ped: 0.5-1mg/kg PO/IM q 4-6hrs, max 60mg dose.