DRUG STUDY ON EMERGENCY MEDICINES

ATROPINE SULPHATE
Introduction:- Atropine sulphate is the “Anticholinergic drug” which block the action of acetylcholine on autonomic effectors and the CNS exerted through
muscarinic receptors. These anticholinergic drugs are also referred as Muscarinic receptor antagonists and parasympatholytic. Atropine is the natural alkaloid
and is highly selective for muscarinic receptors. The natural alkaloids are found in plants of the Solanaceae family.

Generic Name:- Atropine Sulphate

Brand Name:- Isopto Atropine, Atrotas
Class:- Anticholinergics or Parasympatholytic
Subclass:- Antimuscarinic

Dosage/Route:-
 Adult:- Bradycardia: 0.5mg IV every 3-5 mins, maximum of 0.04 mg/kg
Cardiac arrest:- 1mg every 3-5 mins
Anesthesia adjunct 0.4-06 mg/SC/IM/IV every 4-6 hours [ 1ST dose to be given 30- 60min
Organophosphate nerve agent poisoning:- 2mg IV/IM every 5-10 min prn]
 Children:- Bradycardia 0.02mg/kg/iv
Anesthesia adjunct:- 0.02mg/kg SC/IM/IV
 Organophosphate nerve agent poisoning:- 0.05mg/Kg/IM

Drug interactions:-
 It affect the growth hormone diagnostic test result and anticholinergic effects, so contraindicated with potassium acid phosphate, potassium chloride,
potassium citrate and potassium phosphate.
 Antacid interfere with anticholinergic absorption.
 MAOs inhibitor interfere with metabolism of anticholinergic.

Mechanism of action:- The action of atropine is as that of parasympathetic responses. Prominent effect are seen in organs which normally receive strong
parasympathetic tone. Atropine blocks all subtype of muscarinic receptors. The anticholinesterase usually react with the enzyme essentially in the same way
as acetylcholine.
Pharmacokinetics:-
 Absorption:- Atropine rapidly absorbed from GI tract, and penetrate cornea when applied to eyes.
 Distribution:- Crosses placental barrier, crosses blood brain barrier.
 Metabolism:- 50% metabolised in liver where the drug is hydrolysed to tropine and tropic acid.
 Elimination:- Remaining is excreted unchanged in urine. It has half-life of 3-4 hours

Indications:-
1. As antisecretory:-
a) Preanesthetic medication:- Prior Anesthesia atropine administered to reduce increased salivary and tracheal secretions.
b) Peptic ulcer:- Reduce gastric secretions and relief secretions.
c) Pulmonary embolism:- These drug benefit by reducing pulmonary secretions evoked reflexly by embolism.
d) Parkinsonism:- To reduce excessive sweating or salivation.

2. As antispasmodic:-
a) Intestinal and renal colic.
b) Drug induced diarrhoea
c) To reduce urinary frequency and urgency.
3. Bronchial asthma, asthmatic bronchitis, COPD
4. To antagonise muscarinic effect of drugs and poison
5. Motion sickness
6. Antidote for cholinergic toxicity
7. To lessen the degree of A-V heart block
Contraindications:-
 Narrow iridocorneal angle
 Acute congestive glaucoma
 Prostatic hypertrophy
 Bladder obstruction
 Pregnancy breast feeding
 Dental diseases
 Ambient temperature increase, dehydration, fever, strenuous exercises.

Adverse effect:-
 CNS
Dizziness
confusion
Loss of balance
Hallucinations
Excitations
 CVS
Palpitation
Increased heart rate
Ventricular fibrillation
Supra ventricular or ventricular tachycardia
 EENT
Dry mouth
Large pupils
Photophobia
Blurred vision
 GI
 Decreased gastric secretions
Difficulty in swallowing and talking
Decreased bowel sound
 Hematology
Dry flushed and hot skin
 Urinary
Difficulty in micturition
Urinary retention

Nursing Responsibilities:-
Before  Assess for the history of allergy to anticholinesterase.
 Before administering the atropine the nurse must know the indication for
which it is going to be administered.
 Nurse must have complete knowledge regarding the atropine, dose, rote,
indication, side effect, mechanism and action etc.
 Check for prescription written order must be there, while the atropine is
administered in emergency use repeat back policy to avoid medication order.
 Check complete baseline data, monitor vitals , Heart rate etc.
 Have patient to void before taking medicines if urinary retention is problem.
During  Check vital signs of patient and ECG finding, report any significant finding in
heart rate and blood pressure, increased ventricular ectopy or angina and report
to physician.
 Check for the sign of hypersensitivity
After  Check for the desired outcome.
 Carefully monitoring the patient for palpitation, increased heart rate,
tachycardia or other associated complications.
 Ensure adequate hydration, provide environmental control to prevent
hyperpyrexia.
 Keep patient mouth moisturized as patient will have dry mouth.
 Ask the patient for any blurred vision or other vision related problems.
  Close monitoring of urine output in elderly and surgical patient as atropine will
decrease the urine output.
 Assess patient for abdominal distention and auscultate for bowel sound. If
constipation is a problem adding fluids and bulk to diet may help alleviating
the constipation.
 Overdose or toxicity occur in case Physostigmine is administered.

EPINEPHRINE
Introduction:- Epinephrine, also known as adrenalin is a medication and hormone. Epinephrine is normally produced by both the adrenal glands and
certain neurons. It plays an important role in the fight-or-flight response by increasing blood flow to muscles, output of the heart, pupil dilation, and blood
sugar. Jokichi Takamine first isolated epinephrine in 1901.
Generic Name:- Adrenaline
Brand Name:- Epipen, adrenaclick, vasocon
Classification:- Anticholinergics
Subclass:- Cardiac stimulant

Dosage/Route:-
 Adult:- 0.2-0.5mg SC/IM every 5 min according to BP, pulse and respiratory function.
 Children:- Over 12 years – 0.5mg IM [0.5ml 1:1000]
6-12 years - 0.3mg IM [0.3ml 1:1000]
6months to 6 years - 0.15mg IM [0.15ml 1:1000]
Under 6 months - 0.01mg/kg IM [0.01ml/kg 1:1000]

Drug interaction:-
 Drug-Drug:-
 Concurrent use with the other adrenergic agents will have additive adrenergic side effects.
 Use with MAOs inhibitors may lead to hypertensive crisis
 Beta blocker may negate the therapeutic effect.
 Drug- Natural products:- Use with ephedra containing and caffeine containing herbs like cola nut, mate, tea, coffee increase stimulant effect.

Mechanism of epinephrine :- As a hormone, epinephrine acts on nearly all body tissues. Its actions vary by tissue type and tissue expression of adrenergic
receptors. For example, high levels of epinephrine causes smooth muscle relaxation in the airways but causes contraction of the smooth muscle that lines
most arterioles. Epinephrine acts by binding to a variety of adrenergic receptors. Epinephrine is a nonselective agonist of all adrenergic receptors, including
the major subtypes α1, α2, β1, β2, and β3. Epinephrine's binding to these receptors triggers a number of metabolic changes. Binding to α-adrenergic receptors
inhibits insulin secretion by the pancreas, stimulates glycogenolysis in the liver and muscle, and stimulates glycolysis and inhibits insulin-
mediated glycogenesis in muscle. β adrenergic receptor binding triggers glucagon secretion in the pancreas, increased adrenocorticotropic hormone (ACTH)
secretion by the pituitary gland, and increased lipolysis by adipose tissue. Together, these effects lead to increased blood glucose and fatty acids, providing
substrates for energy production within cells throughout the body. In the heart, the coronary arteries have a predominance of β2 receptors, which
cause vasodilation of the coronary arteries in the presence of epinephrine.
Its actions are to increase peripheral resistance via α1 receptor-dependent vasoconstriction and to increase cardiac output via its binding to β1 receptors. The
goal of reducing peripheral circulation is to increase coronary and cerebral perfusion pressures and therefore increase oxygen exchange at the cellular level.
While epinephrine does increase aortic, cerebral, and carotid circulation pressure.

Pharmacokinetics:-
 Absorption:- Absorption depend upon the route through which the medicine injected, Intramuscular absorption is faster than the subcutaneous route.
 Distribution:- Widely distributed, through placenta and milk maternal administration done while keeping the maternal benefit in view. Does not cross
blood brain barrier.
 Metabolism:- Adrenergic synapses, uptake by nerve endings.
 Elimination:- Excreted through urine

Indications:-
 Cardiac arrest
 Partial or complete AV block
 Congestive heart failure
 Hypotensive state
 Superficial bleeding
 Hypoglycaemia
 Along with local anesthesia
 Nasal decongestant
 Bronchospasm
 Bronchial asthma and COPD
 Allergic disorders like urticaria, angioedema
 Anaphylaxis

Contraindications:-
 Hypersensitivity to adrenergic amines
 Hypertension
 Hyperthyroid
 Angina
 Narrow angle glaucoma

Adverse effect:-
 CNS:-
Headache
Tremor
Shakiness
Anxiety
 CVS:-
Palpitation
Fast heart rate
High blood pressure
Abnormal heart rhythm occasionally
 Respiratory:-
Pulmonary edema
 EENT:-
Deposition of adrenochrome pigment in conjunctiva, iris , lens and retina
 GI:-
Decreased bowel movement
Nausea
Vomiting
 Endocrine
Hyperglycemia

Nursing Responsibilities:-
Before  Assess for the history of allergy to catecholamines.
 Before administering the adrenaline the nurse must know the indication
for which it is going to be administered.
 Nurse must have complete knowledge regarding the adrenaline, dose,
rote, indication, side effect, mechanism and action etc.
 Check for prescription written order must be there, while the adrenaline
is administered in emergency use repeat back policy to avoid medication
order.
 Check complete baseline data, monitor vitals , Heart rate etc.
During  Check BP, pulse, ECG, respiratory rate, frequently during the IV
administration. Continuous ECG monitoring, hemodynamic parameters
and urine output should be monitored continuously during IV
administration.
 Monitor for chest pain, arrythmias, heart rate >110bpm and hypertension.
 Assess volume status.
After  May cause transient decrease in serum potassium concentrations with
nebulization or at higher than recommended doses.
 May cause increase in blood glucose and serum lactic acid concentration,
careful monitoring must be done.
 TOXICITY AND OVERDOSE:- Symptoms of overdose include
persistent agitation, chest pain or discomfort, decreased blood pressure,
dizziness, hyperglycemia, hypertension, hypokalemia, seizure,
tachyarrhythmias, persistent trembling and vomiting.
  Treatment includes discontinuing adrenergic bronchodilator and other
beta-adrenergic agonist and symptomatic, supportive therapy, cardio
selective beta blocker agents are used cautiously, because they may
induce bronchospasm.

HYDROCORTISONE
Introduction:- Hydrocortisone sold under the many brand numbers, is the name for the hormone cortisol when supplied as the medication. Hydrocortisone
can be given in oral form, topically or by injection. Stopping treatment after long term use should be done slowly as abrupt interruption may lead to lots of
withdrawal symptoms, and imbalances. They bind to glucocorticoid receptors that is present in almost every cell of vertebrates.
Generic Name:- Hydrocortisone
Brand Name:- Enzone, promosone
Classification:- Corticosteroids

Availability:-
Tablet 5mg, 10mg, 20mg
Oral suspension 10mg/5ml
Suspension for injection:- 25mg/ml, 50mg/ml
Solution for injection:- 50mg/ml
Powder for injection:- 100mg, 250mg, 500mg, 1gm

Dosage/Route:-
 Adult:- 15-240mg oral/IM/IV every 12th hourly
 Children under 12 years:- 2.5-10mg/kg/day orally divided every 6-8 hours
 Children 12 years and above:- 15-240mg oral/IM/IV every 12th hourly.

Drug interaction:-
 Drug-Drug interaction:-
 Additive hypokalemia with thiazides and loop diuretic, amphotericin B.
 Hypokalemia may increase the risk of digoxin.
 May increase requirement for insulin or oral hypoglycaemic agent.
 Hormonal contraceptive block the metabolism.
 Drug-Food interaction:- Grapefruit juice increase the serum level concurrent use should be avoided.

Mechanism of action:- Hydrocortisone is called life saving drug as it supress the inflammation and the normal immune response. Cortisol is the major
glucocorticoid secreted from the body, in conditions leading to deficiency of the glucocorticoid the hydro corticoid is administered to increase its level in
body. It also act as potent mineralocorticoid.

Pharmacokinetics
 Absorption:- Well absorbed after oral administration. Absorption from local site is slow but complete.
 Distribution:- Widely distributed, cross the placenta and probably enter the breast milk.
 Metabolism and excretion:- Metabolized in liver. Cortisone is converted by liver to hydrocortisone. Half life of hydrocortisone is 1.5-2 hours.

Indication:-
 Adrenocortical insufficiency
 Allergy
 Inflammation
 Autoimmune disorders
 Asthma
 Organ transplant
 Physiologic replacement
 Hyperaldosteronism
 Decompensated heart failure

Contraindication:-
 Hypersensitivity
 Active untreated infection
 Lactation
 Known alcohol hypersensitivity
 Use cautiously in:-
 Chronic treatment as it will lead to adrenal suppression so use smallest possible dose for short time.
 Pregnancy
 Children
 Potential risk
 Stress

Adverse effect:-
CNS:- Depression, euphoria, headache, increased ICP, personality change, psychosis, restlessness.
EENT:- Cataract, increased intraocular pressure.
CV:- Hypertension
GI:- Peptic ulcer, anorexia, nausea, vomiting
SKIN- Acne, wound healing, ecchymosis, fragility, hirsutism, petechia.
ENDO:- Adrenal suppression, hyperglycemia
Fluid and electrolyte:- Fluid retention, hypokalemic alkalosis,
Hematology:- Thromboembolism, thrombophlebitis
Metabolic change:- Weight gain, weight loss.
Musculoskeletal:- Muscle wasting, osteoporosis, aseptic necrosis of joint, muscle pain.
Immunity:- Increased susceptibility to infection

Nursing responsibilities:-
Before  Assess for the history of allergy to hydro corticosteroid.
 Drug administered for many conditions, assess involved system before
and periodically throughout the therapy.
 Before administering the hydrocortisone the nurse must know the
indication for which it is going to be administered.
 Nurse must have complete knowledge regarding the hydrocortisone ,
dose, rote, indication, side effect, mechanism and action etc.
 Check for prescription written order must be there.
 Check complete baseline data, monitor vitals, blood sugar.
During  Check BP, pulse, ECG, respiratory rate, frequently during the IV
administration. Continuous ECG monitoring, hemodynamic parameters
and urine output should be monitored continuously during IV
administration.
After  Assess patient for signs of adrenal insufficiency i.e hypotension, nausea,
vomiting, anorexia, lethargy, confusion.
 Monitor intake and output ratios and daily weight gain, rales/crackles or
dyspnoea, notify immediately.
  Children should be evaluated for periodic growth.
 Assess patient for cerebral edema manifested as change in level of
consciousness and headache.
 Monitor serum electrolyte and glucose, as it causes hyperglycemia
especially in diabetic patient.
 Assess for any signs of infection as it leads to immunosuppression.

DOPAMINE

Introduction:- Dopamine is an organic chemical of the catecholamine and phenylamine families that plays several important roles in the brain and body. It
is an amine synthesized by removing a carboxyl group from a molecule of its precursor chemical L-DOPA, which is synthesized in brain and kidney. It is
also synthesized in most of animals and plant. In the brain, dopamine functions as a neurotransmitter a chemical released by neurons (nerve cells) to send
signals to other nerve cells. The brain includes several distinct dopamine pathways, one of which plays a major role in the motivational component
of reward-motivated behavior. The anticipation of most types of rewards increases the level of dopamine in the brain, and many addictive drugs increase
dopamine release or block its reuptake into neurons following release. Other brain dopamine pathways are involved in motor control and in controlling the
release of various hormones. These pathways and cell groups form a dopamine system which is neuromodulatory.

Generic name:- Dopamine

Brand name:- Intropin,
Therapeutic class:- Ionotropic, Vasopressors
Pharmacological class:- Adrenergics
Drug availability:- Injection for dilution:- 40mg/ml, 80mg/ml, 160mg/ml.
Premixed injection:- 0.8mg/ml, 1.6mg/ml, 3.2mg/ml in 250 and 500 ml D5W.

Dose/Route:-
 Adult:- 0.5-3mcg/kg/min IV
 Continuous infusion:- Dilute 200-400mg in 250-500 ml of 0.9%, D5W for IV infusion.
 Children:- 5-20mcg/kg/min IV

Drug interaction:-
 Drug-Drug interaction:-
 Use with MAOs inhibitors, ergot alkaloids, dexapram, some antidepressant result in severe hypertension.
 Use with general anesthesia may result in hypotension and bradycardia.
 Beta blocker may antagonize cardiac effect.

Mechanism of action:-
 Small dose (0.5-3mcg/kg/min) stimulate dopaminergic receptors producing renal vasodilation.
 Larger dose (2-10mcg/kg/min) stimulate dopaminergic and beta adrenergic receptors producing cardiac stimulation and renal vasodilation.
 Dose greater than 10mcg/kg/min stimulate alpha adrenergic receptors and may cause renal vasoconstriction.
 Therapeutic effects:- Increased cardiac output, increased blood pressure and improved renal blood flow.

Pharmacokinetics:-
 Absorption:- Administered IV only, resulting in complete bioavailability.
 Distribution:- Widely distributed but does not cross blood brain barrier.
 Metabolism and excretion:- Metabolised in liver, kidneys and plasma. Half life is 2 min.
Indications:- Adjunct to standard measures to improve:-
 Cardiac output
 Blood pressure
 Urine output in treatment of shock unresponsive to treatment
Contraindications:-
 Tachyarrhythmia
 Pheochromocytoma
 Hypersensitivity to bisulphites
 Use cautiously in
 Hypovolemia
 Myocardial infarction
 Occlusive vascular disease
 Pregnancy
 Lactation
 Children

Adverse effects:-
 CNS:- Headache
 EENT:- Mydriasis
 Resp:- Dyspnea
 CV:- Arrythmia, hypotension, angina, ECG change, palpitation, vasoconstriction
 GI:- Nausea, vomiting
 Skin:- Piloerection
 Local:- Irritation at IV site

Nursing responsibilities:-

Before  Assess for the history of allergy to hydro dopamine.

 Before administering the dopamine the nurse must know the indication for
which it is going to be administered.
 Nurse must have complete knowledge regarding the dopamine, dose, rote,
indication, side effect, mechanism and action etc.
 Check for prescription written order must be there.
 Check complete baseline data, monitor vitals, blood sugar.
During  Monitor BP, HR, pulse pressure, ECG, pulmonary capillary wedge pressure,
 cardiac output, CVP and urinary output continuously during administration.
Report significant changes in vital signs or arrhythmias.
 If hypotension occurs, administration rate should be increased. If
hypotension persists administer more potent vasoconstrictor.
After  Monitor urine output and report any decrease in urine output.
 Palpate peripheral pulses and assess appearance of extremities routinely.
Notify physician if quality of pulse deteriorate.
 Toxicity or overdose:- If excessive hypertension occur rate of infusion
should be decreased. Although additional measures are usually not
necessarily important because of short duration of dopamine, phentolamine
may be administered if hypertension continues.

AMIODARONE

Introduction:- Amiodarone is an antiarrhythmic medication used to treat and prevent a number of types of irregular heartbeats. It include ventricular
tachycardia, ventricular fibrillation and wide complex tachycardia as well as atrial fibrillation and paroxysmal supraventricular tachycardia. It can be given
by mouth, intravenously, or intraosseously, while when taken by mouth it may take up to few week to show effect.

Generic name:- Amiodarone

Brand name:- Cordarone, Nexterone
Therapeutic class:- Antiarrhythmic
Availability:- Tablets 200mg, 400mg,
Injections:- 50mg/ml, in 3ml ampule

Dose/Route:-
 Adult:- Oral:- 800-1600mg/day in 1-2 doses for 1-3 week then 600-800 mg/day in 1-2 doses for 1 month then 400 mg/day maintenance dose
IV:- 150mg over 10min, followed by 360mg over next 6 hour and then 540mg over the next 18 hour. Continuing infusion at 0.5mg/min until oral therapy.
 Children:- Oral :- 10mg/kg/day for 10 days or until response or adverse reaction occur for weeks then decrease to 2.5mg/kg/day
 IV:- 5mg/kg loading dose over 20-60 min

Drug interaction:-
 Drug-Drug interaction:-
 Increase blood levels and may lead to toxicity from digoxin [decrease dose of digoxin to 50%]
 Increase the blood level of drugs and even may lead to toxicity like Class I antiarrhythmics.
 Increase blood level of cyclosporine, dextromethorphan, methotrexate, phenytoin and theophylline.
 Phenytoin decrease blood level of amiodarone.
 Increase the activity of warfarin [decrease the warfarin by 33-50%].

Pharmacokinetics:-
Absorption:- IV administration result in complete bioavailability. Slowly absorbed from the GI tract.
Distribution:- Distributed to and accumulates slowly in body tissue. Reaches high level in fat, muscle, liver, lungs and spleen. Cross placenta and enter
breast milk.96% bound to plasma proteins.
Metabolism and excretion:- Metabolized by the liver, excreted into bile , minimal renal excretion. Elimination half-life is 58days.

Indications:-
 Management and prophylaxis of life threatening ventricular arrhythmia unresponsive to less toxic agent.
 Management of supraventricular tachyarrhythmia used per orally
 IV:- As part of the advanced cardiac life support ACLS and pediatric advanced life support PALS

Contraindication:- Contraindicated in:-

 Severe sinus node dysfunction
 2nd and 3rd degree AV block
 Bradycardia
 Products containing benzyl alcohol should not be used in neonates.
 Pregnancy and lactation
Use cautiously in:-
 History of CHF
 Thyroid disorder
 Severe pulmonary and liver disease

Adverse effect:-
 CNS:- Dizziness, fatigue, headache, insomnia
 EENT:- Corneal microdeposits, abnormal sense of smell, dry eyes, optic neuritis, optic neuropathy, photophobia
 Resp:- ARDS, pulmonary fibrosis
 CV:- Congestive heart failure, worsening of arrhythmia, bradycardia, hypotension.
 GI:- Liver function abnormalities, anorexia, constipation, nausea, vomiting, abdominal pain, abnormal sense of taste.
 GU:- Decreased libido, epididymitis
 Skin:- Toxic dermal necrosis, photosensitivity, blue discoloration
 Endo:- Hypothyroidism, Hyperthyroidism
 Neuro:- Ataxia, involuntary movement, paresthesia , peripheral neuropathy, poor co-ordination, tremor.

Nursing responsibilities:-

Before  Assess for the history of allergy to amiodarone.

 Before administering the amiodarone the nurse must know the indication for
which it is going to be administered.
 Nurse must have complete knowledge regarding the amiodarone dose, rote,
indication, side effect, mechanism and action etc.
 Check for prescription written order must be there.
 Check complete baseline data, monitor vitals.
During  ECG should be monitored continuously during IV therapy or initiation of oral
therapy. Monitor heart rate, rhythm, PR prolongation.
  Assess patient for sign of pulmonary toxicity.
 IV: assess patient for signs and symptoms of ARDS. Report dyspnea,
tachypnea rales or crackles promptly.
 Monitor blood pressor frequently, hypotension usually occur during first
several hours of therapy and is related to rate of infusion. If hypotension occur
slow rate.
After  Ophthalmic exams should be performed regularly whenever visual change
occur as it may lead to permanent vision loss.
 Assess patient for signs of thyroid dysfunction, lethargy, weight gain, edema of
the hands, feet, periorbital region.
 Monitor AST, ALT and alkaline phosphate throughout the therapy, especially
in patients receiving high maintenance dose.
 BIBLOGRAPHY
1. Deglin Hopfer Judith, “David’s Drug guide for nurses”, 8th edition published by Devis company.
2. www.wikipedia.com
3. Tripathi KD “essentials of Medical Pharmacology”7 th edition published by JP Brothers Medical Publisher (P) Ltd 17/1 Babar Road, Block B,
Shaymali Dhaka Bnagladesh page No. 186, 198, 206,326,512.