Transcript
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Presented by : Dr. jigar thakkar
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CONTENTS
yIntroduction
y
Emergency drug kityRequirement of drug kit
yEmergency drug modules
or levelsyConclusion
y
References
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INTRODUCTION
y All staffs in dental practice must be trained
y All dental offices and the hospitals should maintain at leastthe basic recommended emergency equipment and drugs
y Course of medicine that include all possible conditionlike.seizures, chest pain and respiratorty difficulty etc.
y BLS [P-positioning, A-airway, B-breathing, C-circulation, D-definitive care]
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EMERGENCY KITSy Commercially available or designed
personally
y As simple as possible
y 3 things to be remembered
y Primary management of all emergencysituation involves BLS
y drug administration- not necessary forthe immediate M/o medical emergenciesexcept anaphylaxis
y When in doubt, never medicate
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Requirements of drug kits
y Dental office emergency kit should not becomplicated.
y Should be as simple as possible to use.y It is always best to use a drug with which clinician
is most familiar and comfortable.
y
Should not have too many drugs of similar types,because this leads to confusion and indecision.
y All drug package inserts should be kept in it.
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y Home made kits are always better as clinician will beaware of drug and equipment that should be includedin the kit.
y Select the kit which best fits the individual needs of
his office or augment the kit with separately purchaseditems.
y Drugs and equipments should be included as per theindividuals training.
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EMERGENCY DRUGSEmergency drugs
Module 1 Module 2 Module 3 Module 4
critical drugs
& equipment
non critical drugs
& equipmentACLS antidotal drugs
Injectable drugs and
Non-injectable drugs
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Injectable drugs and Non-injectable drugs
Most injectable emergency drugs: 1ml glass ampuleor vial. c/d as therapeutic dose- except epinephrine
infant one-quarter, Pediatric pt one-half than adult
dose
Non injectable drugs: one tablet or spray is adult
therapeutic dose.
Other items of emergency equipment should be
available in both pediatric and adult forms. E.g. face
masks, airways etc
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DMINISTRATION OF INJECTABLEDRUGS
y Enough of the inj drugsmust enter the blood stream and be transported
to the part of the bodywhere it is needed
y
Ideal route for emergency-IV- onset of actionapproximately 20 sec
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y
IM route- 10 minyVarious sites:
y Mid-deltoid region
y Vastus lateralis
y Gluteal regiony The tongue - Onset of
action - 5-10 min
y Endotracheal
route(when available)
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MODULE ONECritical emergency drugs and equipment
y Injectable drugs1) Epinephrine
2) Histamine blockers
y Noninjectable drugs1) Oxygen
2) Vasodilators
3) Bronchodilator
4)A
ntihypoglycemics5) Aspirin
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y Emergency equipment
1) Oxygen delivery system
2) Suction and suction tips
3) Tourniquets
4)
Syringes5) Magill intubation forceps
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MODULE TWO
yInjectable drugs
y Anticonvulsants
y Analgesics
y Vasopressors
y Antihypoglycemics
y Corticosteroids
y Antihypertensives
y Anticholinergics
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y Noninjectable drugs
y Respiratory stimulant
y Antihypertensives
y Emergency equip
ment
y Scalpel or cricothyrotomy needle
y Artificial airways
y Laryngoscope and endotracheal tubes
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MODULE THREEy Advance cardiovascular life
support(ACLS) essential
drugs
y Epinephrine
y Oxygen
y Lidocaine
y
Atropiney Dopamine
y Morphine sulphate
y Verapamil
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MODULE FOUR
y Anti dotal drugs
y Opioid antagonist
y Benzodiazepine antagonist
y Antiemergence delirium drug
y Vasodilator / local anesthetic
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MODULE ONECritical emergency drugs and equipment
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Primary injectable:drug for acute allergic reaction
BValuable in management of both
respiratory and cardiovascularmanifestation of acute allergicreaction.
B and agonistBProperties
BRapid onset action, bronchodilator,vasopressor action, histamine- blockingproperties
Baction on heart: HR, SBP, CO,coronary blood flow, DBP
Drug Of Choice : EPINEPHRINE
Drug class: catecholamine
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y Therapeutic indication:
y To treat cases of acute allergic reactiony Acute asthmatic attack
y Mangement of cardiac arrest 1:10,000
y precautions pregnant women
y availibility: in 2 concentrationy Suggested for emergency kit:
y 1 preloaded syringe [1ml of 1:1000 (1mgepinephrine)] and
y
3 to 4 ampules of 1:1000 epinephrine
1:1000
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Primary injectable:for allergic reaction (antihistamine)
Drug Of Choice : Chlorpheniramine
Drug class: Histamine Blocker
Alternative drug: Diphenhydramine
Competitive antagonists of histamine,
Chlorpheniramine is less sedative
than diphenhydramine
Therapeutic indication:
M/o delayed-onset allergic reactions
Definitive m/o acute allergic reaction
As Local anesthetics when the patient has h/o allergy to LA
MOA:
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y Side effects : CNS depression , BP, thickeningof bronchial secretion resulting from drugdrying action
y Contraindication: acute asthma
y Availability:y Chlorpheniramine 10mg/ml (1ml& 2ml ampules)
1ml preloaded syringes
y Diphenhydramine- 10 mg/ml (10 & 30ml multidose vial)
50 mg/ml(1ml & 10ml multidose vial
y
Suggested for emegency kit1 ml of 3 to 4 ampules
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Primary noninjectable :
oxygen(O2)y Most useful
y Supplied variety of sizes
y Recommended E cylinder
provide 02 for approx 30 minutesy Therapeutic indication
y In any emergency situation n whichRespiratory distress is evident,
like.y Contraindicated:
y Rxof hyperventilation
y Suggested for emergency kit
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Primary Noninjectable Drug - Vasodilator
y Drug Action:y Coronary and systemic vasodilator - decreases
peripheral vascular resistance and preload
y Decreases cardiac workload and oxygen demandon the heart
y 2 varieties of available: tab and sprayy Amyl nitrite-inhalant form-act in 10 secy Applied subliguallyy Onset of action: 1 to 2 minsy Shelf life: once exposed to air , is short (abt 12
weeks), stored in pill box
Drug of choice : Nitrogylcerine
Alternative drug : Amyl nitrite
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y Therapeutic indicationy Chest pain
y Definitive m/o angina pectorisy Early m/o actue myocardial infarction
y m/o acute hypertesive episodes
y Contraindication:y hypotensive patient
y Sildenafil(viagra) create drug-druginteraction
y Availabilityy Nitroglycerin tablets , 0.15, 0.3,0.4, 0.6 mg
sublingual tablet &y 0.4 , 0.8 mg/ dose nitroglycerin spray.
y 1 bottle of metered translingualnitrogylcerin spray (0.4 mg
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Primary noninjectable: bronchodilator
y 2 adrenergic agonisty Brochial muscle-relaxing properties with
little/no stimulatory action on the CVS & GIT
y Onset of action within 5 min and lastfor 2-4 hrs
y Therapeutic indication:y To treat brochospasm (acute asthmatic
episodes)
y Allergic reactions with brochospasm
Drug of choice : Albuterol(salbutamol)
Alternative drug : Metaproterenol
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Contraindicatied : in patients with preexisting
tachydysrhythmias from prior use of the drug
Dose: 2-4mg oral, 100-200 mue g by
inhalation
Availability:
Albuterol inhalers
Metaproterenol inhalers
Suggested for emergency kit:
1 metered albuterol inahaler
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Primary noninjectable drug-ntihypoglycemics
y Therapeutic indications:y Hypoglycemic states secondary to
DM or fasting hypoglycemia inconscious pt
y Emergency m/o unconscious pt: inabsence parenteral medication
y No side effecty Availability:
y Glucola, insta-gulcose, fruit juices
Drug of choice : orange juice
Alternative drug : soft drink (non diet)
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Primary noninjectable drug -antiplatelet
Action: inhibits TxA2 production &hasantithrombotic effects lasting > 3 days
Therapeutic indication
Patient with suspected myocardialinfarction or unstable angina
Contraindicated
in recent bleeding ulcer and h/o aspirin allergy
Availability: 65, 81, 162, & 325mg tablets
Suggested for emergency kit : 3 or 4 chewableaspirin ( 162mg)
Drug of choice : aspirin
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Oral surgery in patients on anticoagulant
therapy(aspirin)
y Precautiony For uncomplicated forceps extraction of 1 to 3 teeth, there is
usuallyno need to interfere with aspirin treatmenty In patients receiving up to 100mg daily, bleeding during oral
surgical procedures is controllable with suturing and directpackaging. with gauze, resorbable gelatin sponge, oxidizedcellulose, or microfibrillar collagen.
y I
n patients receiving higher doses ofA
spirin, - bleeding time >20 minutes - surgery should be postponed
y ifemergencysurgical treatment is needed :medical advice shouldbe sought to discontinue the use of aspirin intake 7 days beforeoral surgery procedures
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:57-64)
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Emergency equipment
y O2 delivery systemy Positive pressure
y Bag- valve-mask devicey Pocket mask
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Oxygen delivery systemsy Typesy Positive pressure mask
y Bag valve mask device
y
Full face masky Pocket mask
y Suggested for kity One portable cylinder with positive pressure mask
y
One portable self inflating bag-valve-mask devicey Minimum of one child, one small adult and one large
adult full face mask
y One pocket mask
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y Syringes:
y Suction and aspirating apparatus
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Magill intubation forceps
y Blunt ended scissors withright-angle bend
y Aids in placement of
endotracheal tube duringnasal intubation
y Suggested for emergencykity 1 pediatric size
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Tourniquet
y Types
y Rubber or Velcro tourniquet
y
Rubber tubingy Sphygmomanometer
y Suggested for emergency kit
y 3 tourniquet
y 1 Sphygmomanometer
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Automated external defibrilator
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MODULE TWO:
Secondary (Noncritical) Emegency
Drugs And Equipment
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Secondary injectable drug -NTICONVULSANTS
y
Seizure disorder may occur in thedental office under severalcircumstances.
y Including epileptic seizures, overdose
reaction to LA
, obstructive airway inan unconscious patient, and febrileconvulsion,
y Midazolam preferred over diazepambecause its lack of water solubility-limited iv use
Drug of choice : Midazolam
Drug class: Benzodiazepine
Alternative drug : Diazepam
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y Therapeutic indication:y To treat prolonged seizures
y Local anasthetic- induced seizures
y Hyperventilation
y Thyroid storm
y Side effects Respiratory depressionor arrest
y Availbilityy Midazolam : 5mg/ml in (1,2,5, and 10 ml
vial) and 2ml preloaded syringes
y 1mg/ml in (2ml ampules and 10ml vials) andin 2ml preloaded syringes
y Diazepam : 5mg/ml (2ml ampules and 10mlvials) and 2ml preloaded syringes
y Suggested for emergecy kit:y one 5ml vial of midazolam(5mg/ml)
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Secondary injectable drug -analgesic
y
Action of opioid agonisty Therapeutic indication
y Intense, prolonged pain or anxiety,
y acute myocardial infarction and
y
congestive heart failurey Side effects: CNS and RS depressants
y (recent year n2o -o2 are used)
Drug of choice : Morphine sulphet
Drug class: Opioid agonist
Alternative drug : Meperidine
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y Precaution:y Infant and elderly are more susceptible to
respiratory depressant action of morphiney Dangerous in pt with respiratory insufficiency,
sudden death have occurred
y Conraindicated in head injury
y
Availability:y Morphine sulfate 8,10,and 15mg/ml (in 2 ml
ampules and 20 ml vials
y Meperidine : 50 100 mg/ml (in 1ml ampulesand 20 and 30 ml vials
y Suggested for emergecy kit:y 10mg/ml of morphine sulfate two 2ml ampules
y 50mg/ml of meperidine 2ml ampules
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Secondary injectable drug asopressor
y MOA : receptor agonist
y Onset of action:y methaxone
y Imdiate after IV administration and persist for 1 hr
y After IM : 15 min, persist for 90 min
y Phenylephrine:y 5mg IM dose : SBP to elevate 30mmHg, where DBP
20mmHg and response for last 50min
Drug of choice : phenylephrine
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y Therapeutic indication:y To manage hypotension, in which the status of the pts
heart is unknown and the intent is to raise the BP withoutundue cardiac stimulation
y Syncopal reactions
y Drug overdose reactions
y Postseizure states
y Acute adrenal insufficiency
y Allergyy Contraindicate in pt with high BP/ventricular
tachycardia
y Precaution: hyperthyrodism, bardycardia, partialheart block, myocardial disease, or severe
atherosclerosisy Availability:
y Phenylephrine 10mg/ml (1 ml ampules)
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Secondary injectable drug
antihypoglycemic
y Helps in management of low blood
sugar (hypoglycemia)y Therapeutic indication:
y Antihypoglycemics hypogylcemia
y Diagnostic aid in unconsciousness orseizures of unknown origin.
y Side effects: may produce tissue necrosisif extravascular infiltration occurs
Drug of choice : Dextrose, 50% Solution
Alternative drug : Glucagon
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y Glucagon administeretdeither via IV or IM routes
y Availabilityy 50% dextrose in 50ml glass
ampulesy Glucagon : 1mg of dry powder
with 1 ml of diluent and 10mg ofdry powder with 10ml of diluent.
y Suggested for emergency
kit: 50% dextrose (1-2vial),1mg/ml of glucagone
d i j bl d
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y Onset of action: slow
y Therapeutic indicationsy Definitive m/o acute allergy
y Rx of acute adrenal insufficiency
y Availability:y hydrocortisone sodium succinate 50
mg/ml (2ml vial)
y One 2ml vial
Secondary injectable drug corticosteroid
Drug of choice : Hydrocortisone sodium succinate
drug class : adrenal glucocorticosteroid
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y MOA:y 1selective adrenergic (cardio selective) receptor
blocking agent with a very short duration of axn.
y Therapeutic indicationsy Acute hypertensive episodes
y For m/o intra and postoperative tachycardia and
hypertensiony contraindication:
y bradycardia, Heart block, cardiogenic shock
y Availabilityy 10mg/ml in 10ml vial
Secondaryinjectable drug -antihypertensive
Drug of choice : Esmolol
Drug class: 1 adrenergic blocker
Alternative drug : propranolol
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y Therapeutic indicationsy
To treat bradycardia & haemodynamicallysignificant bradydysrhythmias
y Side effects:y over dose can produce hot , dry skin, headache,
blurred vision, dry mouth & throat, hallucination
y Contra indicated in narrow angle
glaucoma:y Availability
y 0.5mg/ml vials- IM
y 1mg/ml in 10ml preloaded syringe-IV
Secondaryinjectable drug parasympathetic blocking agent
Drug of choice : Atropine
Drug class: anticholinergic
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y MOA:y which irritates MM of URT
y Stimulates respiratory andvasomotor centre ofmedulla
y Resp Bpy Movement of hand and leg
y Therapeutic indicationsy Rx respiratory depression
Secondary non-injectable drug respiratory stimulant
Drug of choice : Aromatic ammonia
Drug class: respiratory stimulant
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y Precaution : in COPD/ Asthma- precipitatebrochospasm
y Availability: silver-gray vaporoles containing 0.3ml
of aromatic ammonia.y 1 or 2 boxes of vaporoles,
d d
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y
Therapeutic indication:y Hypertension,
y Acute anginal pain
y Availability:y 10mg and 20mg capsules
y Sug for emer: One bottle of 10mgcapsules
Secondary non-injectable drug antihypertensive
Drug of choice : Nifedipine
Drug class: ca channel blocker
Alternative drug : nitrogylcerine
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Secondary emergency equipments
y Scalpel and cricothyrotomoy needle
y Suggested for emergency kit
y One scalpel with a disposable blade and one
cricothyrotomy device
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Artificial airways
y Suggested for emergency kit
y One set each of adult and
pediatric airway
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Nasopharangel airway
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Laryngeal mask airway (LMA
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Advanced airway devices
y Suggested for emergency kity One laryngoscope and adult and pediatric size
endotracheal tubes
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A
CLS essential drugs(advancedcardiovascular life support)
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y Epinephrin
y Oxygen
y
Lidocainy Atropin
y Dopamin
y Morphin sulfate
yverapamil
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CLS essential:ntidysrhythmic
y Therapeutic indication:y Premature ventricular contraction occur >6
times/min
y sustained ventricular tachycardia with pulse
y Ventricular fibrillation
y S/E:y increase dose - Myocardial, circulatory, and
CNS depression
y More sever overdose- tonic clonic seizure
Drug of choice : lidocaine(xylocaine)
Drug class: LA, antidysrhythmic
Alternative drug : procainamide
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y Avaibility:y 50 or 100 mg (5ml prefilled syringes)
y 100mg- 5ml ampule
y Suggest for emergency kit:y One 100mg preloaded syringe,
y 5ml ampules
ACLS ti l
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y Chemical precursor of epinephriney MOA:
y in large (stimulates both & receptors
y small dose (dilates renal , mesenteric andcerebral arteries,)
y Therapeutic indication:y To treat haemodynamically significant
hypotension in the absence of hypovolemia
ACLS essential:symptomatic hypotension
Drug of choice : dopamine
Drug class: sympathomimetic amine
Alternative drug : dobutamine
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y S/E:y it increase HR induce supraventicuar or
ventcular dysrhytnmias
y Myocardial ishcmiea-
y
Nausea, vomiting
y Avaibility:y 200, 400, and 800mg in 5-ml ampules
y One or two ampules of 400mgdopamine (80mg/ml)
ACLS i l
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y Therapeutic indication:
y Used primarily to treatparoxysmal supraventiculartachycardia,
MAO-slows conduction through theatrioventricular node
ACLS essential:paroxymal supraventicular tachycardia
Drug of choice : Verapamil
Drug class: Ca channel blocker
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y S/E:y transient decrease arterial pressure
y Contraindicated in ventricular tachycardia
y 2.5mg/ml in 2ml and 4ml ampules
y One or two 4ml ampules
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nti dotal drugs
nti dotal drugs
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nti dotal drugs-Opioid antagonist
y MOA:y I
t reverses other properties of opioids, likeanalgesia and sedation
y Therapeutic indication:y Use in opioid induced depression, including
respiratory depression
y S/E:y
Recurrance rs depression may be observed if theopioid previously administerd in longer duration so give second dose IM after IV
y Adult: 0.4mg/ml in 1-ml ampules and 10ml vialsy Pediatric: 0.02mg/ml in 2ml ampules
Drug of choice : NaloxoneDrug class: Thebaine derivative
Alternative drug : Nalbufine
Anti dotal drugs
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y Uses:
y Its reduce the duration of anterogradeamnesia associated with midazolam (frm 121min to 91 min)
y Use to reverse the clinical actions ofparenterally administered benzodizepines
y 0.1mg/ml in 5ml and 10ml multidosevials
y One 10ml multidose vial of f lumazenil
Anti dotal drugs-benzodiazepine antagonist
Drug of choice : flumazenil
Drug class: benzodiazepine antagonist
Anti dotal drugs
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y Emergence delirium:y
Pt appear lose contact with reality, increase muscularmovement and may seem to speak but make onlyunintelligible sound.
y Scopolamine and benzodiazepines most likely producethis phenomenon
y MOA:y reversible anticholinesterase that can cross BBB
y Therapeutic indication:y To reverse the emergence delirium
Anti dotal drugs-
antiemergence delirium
Drug of choice : physostigmine
Drug class: Reversible Anticholinesterase
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y S/E: bradycardia and hypersalivation
y Contra Indication:
yAsthma , DM, CVS Ds,mechanical obstruction of GIT
y 1mg/ml in 2ml ampules
y 2 or 3 ampules
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y uses:y
To manage vasospasm andcompromised circulation followingintra-arterial drug injection
y To manage pain and vascularcompromise following extra vascularadministration of irritating drugs
y 1%(10mg/ml) solution in 2ml and6ml ampules
y 2 ml ampules
Anti dotal drugs-Vasodilator
Drug of choice : procaine
Drug class: local anesthetic
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Other important drugsy Injection Lasix (Frusemide)y Indications
y Renal failure
y Pulmonary edema
y Forced diuresisi in the treatment of barbiturate
poisioning
yAvailabley 10 mg / ml in 2ml ampule
y Dose
y 20mg IV / IM
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y Sodium bicarbonate
y Indications
y
Following cardiac arresty Correction of metabolic acidosis
y Dose
y 1mEq / kg as IV bolus
y Available as 10ml ampule containing 7.5% solution
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y Aminophylline
y Indications
y
Bronchial asthma
y Dosage
y 12.5 mg / min IV (250 mg diluted in 250cc of sterile
water)
y Availability
y 250mg / 2 ml in 10ml vial
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y Calcium gluconate
y Indications
y After massive blood transfusion
y Cardiac arrest
y As a coagulant
y Availability
y 10 ml ampule with 10% w/v (1gm)
y Dosage
y 100-200mg /kg
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Other equipmentsDefibrillators ECG
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Other essentialsy Alcohol sponges
y IV infusion sets
y IV cathetersy Disposable gloves
y Crystalloidsy NS
y DNS
y RL
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Conclusion
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References:-y Essentials of Medical Pharmacology - KD Tripathi
y Pharmacology and Pharmacokinetics - Satoskar
y
Medical Emergencies in the dental office- Stanley f.Malamed
y Principles and practice of medicine- Davidsons
y Principle of contemporary Peterson
y The pharmacological basis of therapeuticsy Goodman and Gillmans
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