Atropine, the prototype of anticholinergic drugs, produces the same effects, has the same clinical

indications for use, and has the same contraindications as those described earlier. In addition, it is used as
an antidote for an overdose of cholinergic drugs and exposure to insecticides that have cholinergic effects.
Atropine is a naturally occurring belladonna alkaloid that can be extracted from the belladonna plant or
prepared synthetically. It is usually prepared as atropine sulfate, a salt that is very soluble in water. It is
well absorbed from the GI tract and distributed throughout the body. It crosses the blood–brain barrier to
enter the CNS, where large doses produce stimulant effects and toxic doses produce depressant effects.
Atropine is also absorbed systemically when applied locally to mucous membranes. The drug is rapidly
excreted in the urine. Pharmacologic effects are of short duration except for ocular effects, which may last
for several days.

Bupivacaine (Marcaine); Given by injection; May cause systemic toxicity; Effects occur in 5 min and last
2–4 hours with injection, 10–20 min and 3–5 hours with epidural administration
Regional anesthesia by infiltration, nerve block, and epidural anesthesia during childbirth. It is not used for
spinal anesthesia.

Diazepam (Valium); Acute convulsive seizures, status epilepticus; Diazepam and lorazepam are used to
terminate acute convulsive seizures, especially the life-threatening seizures of status epilepticus. Diazepam
has a short duration of action and must be given in repeated doses. In status epilepticus, it is followed with
a long-acting anticonvulsant, such as phenytoin. Lorazepam has become the drug of choice for status
epilepticus because its effects last longer than those of diazepam.

Diclofenac sodium (Voltaren, Voltaren XR); Osteoarthritis, Rheumatoid arthritis, Ankylosing spondylitis
(AS), Pain, dysmenorrhea; Diclofenac sodium (Voltaren) is chemically different from but
pharmacologically similar to other NSAIDs. Formulations are delayed or extended-release and onset of
action is therefore delayed. Peak action occurs in about 2 hours and effects last 12 to 15 hours. Diclofenac
has a serum halflife of about 2 hours and is excreted mainly in the urine. Treatment of inflammation after
cataract surgery; diclofenac is contraindicated in pregnant women.

Ephedrine; asthma- bronchospasm and hypotension; Ephedrine is a mixed-acting adrenergic drug that acts
by stimulating alpha and beta receptors and causing release of norepinephrine. Its actions are less potent but
longer lasting than those of epinephrine. Ephedrine produces more CNS stimulation than other adrenergic
drugs. It may be used in the treatment of bronchial asthma to prevent bronchospasm, but it is less effective
than epinephrine for acute bronchospasm and respiratory distress. Ephedrine is a common ingredient in
OTC anti-asthma tablets (Bronkaid, Primatene, others). Other clinical uses include shock associated with
spinal or epidural anesthesia, Stokes-Adams syndrome (sudden attacks of unconsciousness caused by heart
block), allergic disorders, nasal congestion, and eye disorders.

Epinephrine (Adrenalin); Treat anaphylactic shock, Reverse bronchoconstriction, Increase cardiac output,
Treat cardiac arrest
Epinephrine, a vasoconstrictor, is often added to a local anesthetic to slow systemic absorption, prolong
anesthetic effects, and control bleeding.
Epinephrine (Adrenalin) is the prototype of adrenergic drugs. Specific effects include:
1. Increased systolic blood pressure, due primarily to increased force of myocardial contraction and
vasoconstriction in skin, mucous membranes, and kidneys
2. Vasodilation and increased blood flow to skeletal muscles, heart, and brain
3. Vasoconstriction in peripheral blood vessels. This allows shunting of blood to the heart and brain, with
increased perfusion pressure in the coronary and cerebral
circulations. This action is thought to be the main beneficial effect in cardiac arrest and cardiopulmonary
resuscitation (CPR).
4. Increased heart rate and possibly arrhythmias due to stimulation of conducting tissues in the heart.
Reflex bradycardia may occur when blood pressure is raised.
5. Relaxation of GI smooth muscle
6. Relaxation or dilation of bronchial smooth muscle
7. Increased glucose, lactate, and fatty acids in the blood due to metabolic effects
8. Inhibition of insulin secretion
9. Miscellaneous effects, including increased total leukocyte count, increased rate of blood coagulation, and
decreased intraocular pressure in wide-angle glaucoma. When given locally, the main effect is
vasoconstriction.

Fentanyl citrate (Sublimaze) is a very potent opioid analgesic whose actions are similar to those of
morphine but of shorter duration. Fentanyl may be combined with a small amount of an anesthetic drug for
both analgesia and anesthesia. No significant effects on the fetus occurred in clinical studies.

Halothane (Fluothane) Nonexplosive, nonflammable volatile liquid

Advantages:
1. Produces rapid induction with little or no excitement; rapid recovery with little excitement or nausea and
vomiting
2. Does not irritate respiratory tract mucosa; therefore does not increase saliva and tracheobronchial
secretions
3. Depresses pharyngeal and laryngeal reflexes, which decreases risk of laryngospasm and bronchospasm.
It may be used in balanced anesthesia with other agents. Although quite potent, it may not produce
adequate analgesia and muscle relaxation at a dosage that is not likely to produce significant adverse
effects. Therefore, nitrous oxide is given to increase analgesic effects; a neuromuscular blocking agent is
given to increase muscle relaxation; and an IV barbiturate is used to produce rapid, smooth induction, after
which halothane is given to maintain anesthesia.

Isoflurane (Forane) and Sevoflurane (Ultane)

Similar to halothane but less likely to cause cardiovascular depression and ventricular dysrhythmias.
Isoflurane may cause malignant hyperthermia
Used for induction and maintenance of general anesthesia

Ketamine (Ketalar)
Rapid-acting nonbarbiturate anesthetic; produces marked analgesia, sedation, immobility, amnesia, and a
lack of awareness of surroundings (called dissociative anesthesia); may be given IV or IM; awakening may
require several hours; during recovery, unpleasant psychic symptoms may occur, including dreams and
hallucinations; vomiting, hypersalivation, and transient skin rashes also
may occur during recovery.

Ketorolac (Toradol)
Moderately severe, acute pain, for short term (up to 5 days) treatment
Ketorolac is used only for pain, and although it can be given orally, its unique characteristic is that it can be
given by injection. Parenteral ketorolac reportedly compares with morphine and other opioids in analgesic
effectiveness for moderate or severe pain. However, its use is limited to 5 days because it increases the risk
of bleeding. Hematomas and wound bleeding have been reported with postoperative use. ketorolac is
contraindicated in clients at risk of excessive bleeding.
Thus, ketorolac should not be administered during labor and delivery; before or during any major surgery;
with suspected or confirmed cerebrovascular bleeding; or to clients who are currently taking aspirin or
other NSAIDs.
Ketorolac (Acular)
Treatment of ocular itching due to seasonal allergic conjunctivitis

Lidocaine, a local anesthetic, is the prototype of class IB. It is the drug of choice for treating serious
ventricular dysrhythmias associated with acute myocardial infarction,
cardiac surgery, cardiac catheterization, and electrical cardioversion. Lidocaine decreases myocardial
irritability (automaticity) in the ventricles. It has little effect on atrial tissue and
is not useful in treating atrial dysrhythmias. It differs from quinidine in that:
1. It must be given by injection.
2. It does not decrease AV conduction or myocardial contractility with usual therapeutic doses.
3. It has a rapid onset and short duration of action. After intravenous (IV) administration of a bolus dose,
therapeutic effects occur within 1 to 2 minutes and last approximately 20 minutes. This characteristic is
advantageous in emergency management but limits lidocaine use to acute care settings.
4. It is metabolized in the liver. Dosage must be reduced in clients with hepatic insufficiency or heart
failure to avoid drug accumulation and toxicity.
5. It is less likely to cause heart block, cardiac asystole, ventricular dysrhythmias, and heart failure.
Therapeutic serum levels of lidocaine are 2 to 5 mcg/mL. Lidocaine may be given intramuscularly (IM) in
emergencies when IV administration is impossible. When given IM, therapeutic effects occur in about 15
minutes and last about 90 minutes. Lidocaine is contraindicated in clients allergic to related local
anesthetics (eg, procaine). Anaphylactic reactions may occur in sensitized individuals.

Meperidine (Demerol) is an opioid analgesic that is used to manage severe pain. Its abuse potential is high
and it is therefore given a Schedule II classification. Cause less neonatal depresion.

Methergine is used for management of postpartum hemorrhage related to uterine atony.

Oxytocin is a hormone produced in the hypothalamus and released by the posterior pituitary gland.
Oxytocin stimulates uterine contractions to initiate labor and promotes letdown of
breast milk to the nipples in lactation. Pitocin is a synthetic form used to induce labor at or near full-term
gestation and to augment labor when uterine contractions are weak and ineffective. It also can be used to
prevent or control uterine bleeding after delivery or to complete an incomplete abortion. It is
contraindicated for antepartum use in the presence
of fetal distress, cephalopelvic disproportion, preterm labor, placenta previa, previous uterine surgery, and
severe preeclampsia.

Metoclopramide (Reglan or Plasil) is a prokinetic agent that increases GI motility and the rate of gastric
emptying by increasing the release of acetylcholine from nerve endings in the GI tract (peripheral
cholinergic effects). As a result, it can decrease nausea and vomiting associated with gastroparesis and
other nonobstructive disorders characterized by gastric retention
of food and fluids. Metoclopramide also has central antiemetic effects; it antagonizes the action of
dopamine, a catecholamine neurotransmitter. Metoclopramide is given orally in diabetic gastroparesis and
esophageal reflux. Large doses of the drug are given intravenously during chemotherapy with cisplatin
(Platinol) and other emetogenic antineoplastic drugs.

Midazolam (Versed) Short-acting benzodiazepine. May cause respiratory depression, apnea, death with IV
administration. Midazolam has a rapid onset and short duration of action, causes amnesia, produces
minimal cardiovascular side effects, and reduces the dose of opioid analgesics required during surgery. It is
often used in ambulatory surgical or invasive diagnostic procedures and regional anesthesia.

Misoprostol (Cytotec) Prevention of aspirin and NSAID-induced gastric ulcers in selected clients
Misoprostol is a synthetic form of prostaglandin E approved for concurrent use with NSAIDs to protect
gastric mucosa from NSAID-induced erosion and ulceration. It is indicated
for clients at high risk of GI ulceration and bleeding, such as those taking high doses of NSAIDs for
arthritis and older adults. It is contraindicated in women of childbearing potential,
unless effective contraceptive methods are being used, and during pregnancy, because it may induce
abortion. The most common adverse effects are diarrhea (occurs in 10% to
40% of recipients) and abdominal cramping. Older adults may be unable to tolerate misoprostol-induced
diarrhea and abdominal discomfort.

Morphine is the prototype of opioid analgesics, Opiates are potent analgesics and extensively used in pain
management. They are also commonly abused. Duramorph is a long-acting form of morphine that provides
analgesia up to 24 hours after injection into the epidural catheter at the completion of a cesarean section.

Nalbuphine (Nubain) opioid agonist-antagonist

Naloxone (Narcan) Acute intoxication or overdose of opiates (heroin, morphine, others)

Promethazine (Phenergan) Hypersensitivity reactions (allergic rhinitis, conjunctivitis, dermatitis)

Sedation, Antiemetic, Motion sickness
Phenergan are strong CNS depressants and cause extensive drowsiness.

Ranitidine (Zantac)- Histamine-2 Receptor Antagonists

The H2RAs inhibit both basal secretion of gastric acid and the secretion stimulated by histamine,
acetylcholine, and gastrin. They decrease the amount, acidity, and pepsin content of gastric juices. A single
dose of an H2RA can inhibit acid secretion for 6 to 12 hours and a continuous intravenous (IV) infusion
can inhibit secretion for prolonged periods.

Tramadol- inhibits reuptake of serotonin and norepinephrine; opioid agonist