Emergency drugs

this presentation includes the various emergency drugs as well as emergency kits that we as dentists should keep in our dental clinics and hospitals for emergency purposes.

1. PRESENTED BY:- DR MEENAL ATHARKAR MDS DEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICS EMERGENCY DRUGS AND NSAID’s

2. CONTENTS: Emergency drugs Introduction Purpose of emergency drugs Category of emergency drugs Modules of emergency drugs Emergency drug kit

3. INTRODUCTION: Everyone has personal experience pain in day to day life. One of the greatest services, we as doctors can provide to the society is to acquire skill in the management of pain and to understand the phenomenon of pain. Among the various novel methods for control of pain, analgesics are most frequently used for pain relief.

4. 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.

5. PURPOSE OF DRUGS: To provide initial treatment for broad spectrum of illness and injuries, most of which are life threatening. To save life of patient. To control symptoms of patient. To reach the site of action as soon as possible. To normalize the vital body functions. To diverge the patient from possible risk.

6. CATEGORY OF EMERGENCY DRUGS:

7. ROUTES OF DRUG ADMINISTRATION, BY ONSET OF ACTION (FASTEST TO SLOWEST) Endotracheal (ET) (when available): epinephrine, lidocaine , atropine, naloxone , and flumazenil only Intravenous (IV) Sublingual or intralingual Intranasal (IN): midazolam Intramuscular (IM) Vastus lateralis Mid-deltoid Gluteal region

8. MODULES OF EMERGENCY DRUGS: four levels, or modules. Module one: Basic emergency kit (critical drugs and equipment) Module two: Noncritical drugs and equipment Module three: ACLS drugs Module four: Antidotal drugs Two categories are described for each module— injectable and noninjectable drugs, as well as emergency equipment.

9. 1}Module One: Critical (Essential) Emergency Drugs and Equipments > INJECTABLE DRUGS Epinephrine Histamine blocker > NONINJECTABLE DRUGS Oxygen Vasodilator Bronchodilator Antihypoglycemics Aspirin > EMERGENCY EQUIPMENTS O2 delivery system Automated external defibrillator Syringes Suction and suction tips Tourniquets Magill intubation forceps

10. 2}Module Two: Secondary (Noncritical) Emergency Drugs and Equipments Injectable drugs Anticonvulsant Analgesic Vasopressor Antihypoglycemic Corticosteroid Antihypertensive Anticholinergic Noninjectable drugs Respiratory stimulant Antihypertensives Emergency equipments Oropharyngeal and nasopharyngeal airways Laryngeal mask airway Laryngoscope and endotracheal tubes Scalpel or cricothyrotomy needle

11. 3}Module Three: Advanced Cardiovascular Life Support (ACLS) Epinephrine Oxygen Lidocaine Atropine Dopamine Morphine sulphate verapamil

12. 4}Module Four: Antidotal Drugs Opioid antagonist- naloxane Benzodiazepine antagonist- flumazenil Antiemergence delirium drug- physostigmine Vasodilator/ LA- procaine

13. Module 1: INJECTABLE DRUGS: 1. EPINEPHRINE: Drug class- natural cotecholamine Indications-Epinephrine in a 1:1000 or 1:2000 concentration is used to treat cases of acute allergic reactions and bronchospasm . -1:10,000 concentration is recommended in the management of cardiac arrest - angioedema and anaphylactic shock - open angle glaucoma Each kit should have two preloaded autoinjector syringes of 1:1000 epinephrine

14. Contraindications- Hyperthyroidism Hypertension Ischemic heart diseases Diabetes Angle closure glaucoma

15. 2. ANTIHISTAMINES Drug of choice- chlorpheniramine Alternative drug- diphenhydramine HCL ( benadryl ) Histamine blockers are competitive antagonists of histamine; they do not prevent the release of histamine from cells in response to injury, drugs, or antigens but do prevent histamine’s access to its receptor site on the cell, blocking the response of the effector cell to histamine. Indications-Histamine blockers are recommended in management of delayed-onset allergic reactions (only involving skin) - in definitive management of acute life-threatening allergic reactions (anaphylaxis). - for local anesthesia The emergency kit should contain a minimum of two 1-mL ampules of either diphenhydramine (50 mg/ mL ) or chlorpheniramine (10 mg/ mL ).

16. NONINJECTABLE DRUGS: 1.OXYGEN: The most useful drug in the entire emergency kit is oxygen, which is supplied in a variety of sizes of compressed gas cylinders. In emergency situations an E cylinder provides O2 for approximately 30 minutes (if the patient is apneic ). Larger cylinders (H cylinders) provide significantly more O2 but are less portable; smaller cylinders (A through D cylinders) contain too little O2 to be clinically effective for more than an extremely short duration. O2 produced through a chemical reaction in small canisters is not adequate for an emergency kit. An E cylinder of O2 is quite portable and should be available in dental offices even where centrally supplied nitrous oxide (N2O) and O2 are used.

17. 2. VASODILATORS: 1. nitroglycerine : Nitrolingual spray, Nitrostat tablets Indications-With onset of first-time chest pain, nitroglycerin is used as an aid in differential diagnosis and for the definitive management of angina pectoris, the early management of acute myocardial infarction, and the management of acute hypertensive episodes. Nitroglycerin is available in the following forms: 0.3-, 0.4-, 0.6-mg doses of sublingual tablets; 0.4- and 0.8-mg doses of trans lingual spray. Act in 1-2 mins when placed sublingually. 2. Amyl nitrite is available as 0.3-mL doses in yellow vaporoles . Emergency drug kits should contain either one bottle of sublingual tablets or one bottle of metered trans lingual Nitroglycerin spray (0.4 mg).

18. Contraindications- Obstructive hypertrophic cardiomyopathy Raised intracranial pressure Cardiac tamponade

19. 3.BRONCHODILATOR: Albuterol , Salbutamol Proprietary: Proventil, Ventolin, Proair, Respirol, Volmax β2- adrenergic receptor agonists specific bronchial smooth muscle– relaxing properties (β2) with little or no stimulatory action on the cardiovascular and gastrointestinal systems (β1) indications:- Bronchodilators are used to treat bronchospasm (acute asthmatic episodes) and allergic reactions in which bronchospasm is a component

20. 4.ANTIHYPOGLYCEMICS: Orange juice /Glucose Gel ( Insta -Glucose™) Indications- Antihypoglycemics are useful in the management of hypoglycemia in patients with diabetes mellitus. Antihypoglycemics come in a variety of forms, including Glucola , Gluco -Stat, Insta -Glucose, Contraindications- oral carbohydrates should not be administered to patients who do not have an active gag reflex

21. 5. ANTIPLATELET: Aspirin: Standard doses range from 160 to 324 mg given orally. Minimal side effects are noted, particularly with the 160 mg dose. Aspirin is available in 65-, 81-, 162-, and 325-mg tablets under many brand names. Powdered forms of aspirin are available and are preferred to tablets as their onset of action is more rapid Indication- Aspirin is recommended in the management of patients with suspected myocardial infarction or unstable angina. The emergency kit should include powdered or chewable aspirin (325 mg)

22. CRITICAL EMERGENCY EQUIPMENTS: O2 delivery system Automated external defibrillator Syringes Suction and suction tips Tourniquets Magill intubation forceps

23. MODULE 2: INJECTABLE: 1. ANTICONVULSANTS- MIDAZOLAM: Midazolam ( Hypnovel and Dormicum [Europe, Great Britain]) is available as 5 mg/ mL in 1-, 2-, 5-, and 10-mL vials and in 2-mL preloaded syringes, and 1 mg/ mL in 2-, 5-, and 10-mL vials. The well-known proprietary name of midazolam —Versed—is no longer marketed. Diazepam is available as 5 mg/ mL in 2-mL ampules and 10-mL vials and in 2-mL preloaded syringes. Indication- Midazolam is used to treat prolonged seizures , local anesthetic -induced seizures, hyperventilation, and thyroid storm. emergency kit-- One 5-mL vial of midazolam (5 mg/ mL )

24. Drug of choice- diazepam-benzodiazepine Alternative drug- barbiturates( thiopentane ) Seizure disorders may occur in dental office in several circumstances: Overdose reactions of LA. Epileptic seizures Febrile convulsions Indications- termination of prolonged seizures - local anesthetic seizures - hyperventilation syndrome - thyroid storm Avaliability - diazepam( valium )-5 mg/ml(2ml preloaded syringe)

25. 2.ANALGESIC : Morphine sulfate Alternative drug-- Nitrous oxide and oxygen (N2O-O2)/ meperidine Narcotic analgesic action Morphine sulfate is available 8, 10, and 15 mg/ mL (in 2-mL ampules and 20-mL vials) Indications-Intense, prolonged pain or anxiety; acute myocardial infarction; congestive heart failure Emergency kits may contain 10 mg/ mL morphine sulfate (two 2-mL ampules ).

26. Contraindications- In victims of head injury and multiple trauma Patients with compromised respiration

27. 3. VASOPRESSORS: Drug of choice- methoxamine Alternative drug- phenylephrine Pure alpha adrenoceptor agonist Vasopressors are used to manage clinically significant hypotension. Possible uses include the following: Syncopal reactions Drug overdose reactions Postseizure states Acute adrenal insufficiency Allergy Availability- methoxamine - 10 mg/ml, 20 mg/ml - phenylephrine-10 mg/ml(1 ml ampule ).

28. Contraindications- Hyperthyroidism Bradycardia Partial heart block Myocardial disease Severe artherosclerosis

29. 4.ANTIHYPOGLYCEMIC: Dextrose, 50% solution /Glucagon 1 mg/ mL (two or three 1-mL vials) of glucagon for IV or IM administration indications- Antihypoglycemics are used in the treatment of hypoglycemia and as a diagnostic aid in unconsciousness or seizures of unknown origin Contraindications- in starvation state Chronic hypoglycemia

30. 5.CORTICOSTEROID Drug of choice- hydrocortisone sodium succinate Alternative drug- methyl prednisolone sodium succinate Primary value- in prevention of recurrent episodes of anaphylaxis Adrenal glucocorticosteroid Availability- Hydrocortisone sodium succinate- 50mg/ml(one 2-mL vial). - methyl prednisolone- 50mg/ml (1ml vial)

31. Indications- definitive management of acute allergy - status asthamaticus - apthous ulcer - acute adrenal insufficiency - congenital adrenal hyperplasia Contraindications- when administered for an emergency treatment there are many factors to be considered such as presence of pre-existing injection, peptic ulcer and hyperglycemia

32. 6.ANTIHYPERTENSIVES: Drug of choice- esmolol , propanolol β- adrenergic blocker Alternative drug : Labetalol Indications-Acute hypertensive episodes Availability- Esmolol is available as 2.5 g in a 10-mL ampule , which is diluted to a 10-mg/ mL concentration prior to infusion, and as a 100-mg/ mL solution, which is also diluted to 10-mg/ mL prior to administration. Emergency kit- Two ampules 100 mg/ mL with diluent .

33. 7.PARASYMPATHETIC BLOCKING AGENT/ANTICHOLINERGIC DRUG: Atropine is a parasympatholytic drug that decreases vagal tone through its vagolytic action, thereby increasing the rate of discharge of sinoatrial node. Atropine is used to treat bradycardia and hemodynamically significant bradydysrhythmias Emergency kit-Two or three ampules of 0.5 mg/ mL (for IM administration) or two 10-mL syringes with 1 mg per syringe (for IV administration).

34. Availability- 5 mg/ml (0.1 mg/ml preloaded syringe) Indications-management of severe sinus bradycardia accompanied by symptomatic hypotension - anesthetic premedication - inhibition of cardiac reflexes - opthalmic use Contraindication- glaucoma - chronic lung disease Conventional dose in adults- 300-600 mg

35. SECONDARY NONINJECTABLE DRUGS Respiratory stimulant Antihypertensives

36. 1.RESPIRATORY STIMULANT: Drug of choice- Aromatic ammonia Aromatic ammonia has a noxious odor and irritates the mucous membrane of the upper respiratory tract, stimulating the respiratory and vasomotor centers of the medulla. This action in turn increases respiration and blood pressure. Indication-Aromatic ammonia is used to treat vasodepressor syncope as well as respiratory depression not induced by opioid analgesics Contraindication- chronic obstructive pulmonary disease, asthama Availability- Silver-gray vaporoles containing 0.3 mL of aromatic ammonia

37. 2. ANTIHYPERTENSIVE Hydralazine : used in the management of high blood pressure. It is a peripheral vasodilator, causing relaxation of arteriolar smooth muscle via a direct effect. Availability- One bottle 25-mg tablets.

38. SECONDARY EMERGENCY EQUIPMENT Oropharyngeal and nasopharyngeal airways Laryngeal mask airway Laryngoscope and endotracheal tubes Scalpel or cricothyrotomy needle

39. Plastic or rubber oropharyngeal or nasopharyngeal airways are used to help maintain a patent airway in the unconscious patient

40. MODULE THREE: ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS)

41. 1. SODIUM BICARBONATE(NAHCO3) During cardiopulmonary arrest, both metabolic and respiratory acidosis occur. NAHCO3 is effective in management of metabolic acidosis. Availability- ( 50 ml ampule ) Indications-reversal of metabolic acidosis occurring during anaerobic metabolism in cardiopulmonary arrest. - management of metabolic acidosis in uncontrolled diabetes, circulatory insufficiency from shock or dehydration, alkanization of urine.

42. Contraindications- in hypoventilatory states - metabolic or respiratory acidosis - hypocalcemia - chloride depletion

43. BASIC EMERGENCY EQUIPMENTS: Tourniquets Syringes Ambu bag Oropharyngeal and nasopharyngeal airways Normal saline 0.9%, 1000-mL bags 18-and 20-gauge angiocatheters Yankauer suction tip Portable oxygen system (E cylinder size) Stethoscope Sphygmomanometer (child and adult sizes) ECG/ defibrillator (AED) Sterile water for injection

44. EMERGENCY DRUG KIT It should be as simple as possible to use. The “KISS” principal is important at this time: “Keep It Simple, Stupid.” Pallasch’s statement that “complexity in a time of adversity breeds chaos” is as true today as it was when written in 1976. Management of all emergency situations follows the (P → A → B →C D) protocol (D = definitive management: diagnosis, drugs, and defibrillation).

45. The doctor should remember three things in preparing and using emergency drug kits: 1. Drug administration is not necessary for the immediate management of medical emergencies (BLS is always implemented, as needed, first). 2. Primary management of all emergency situations involves BLS. 3. When in doubt, don’t medicate (there will be a very specific exception to this in the case of presumed anaphylaxis

46. BASIC DRUG EMERGENCY KIT Epinephrine 1mg/ mL (1:1000 dilution) Dextrose 50% of 50 mL ampule 0.5g/ mL Oxygen Nitro-glycerine tablets or spray 0.4 mg per tablet Albuterol ; metered inhaler Hydrocortisone 300 mg ampule Spirits of ammonia ( vaporable )

47. Self made emergency drug kit

48. CONCLUSION: Based on the knowledge of the pharmacology of the drugs it is necessary to choose the right kind of analgesic suitable to a patient that delivers the desired effect with minimal side effects and provide the best achievable comfort to the patient. Medical emergencies can, and do happen in the practice of dentistry. The essential emergency drug kit and emergency equipment should be kept always in the dental office.

49. REFERENCES: Essentials of pharmacology :K.D . Tripathi Medical emergencies: Malamed Wikipedia