HEADACHES Exclusion criteria: Severe Persist 10 days Last trimester of pregnancy <8 yoa (<12yoa avoid naproxen, 15- yoa with viral sx avoid salicylates) High fever/serious infection Liver disease, 3+ alcoholic drinks daily Secondary headache Migraine sx but no diagnosis Dosing: Pediatric (mg/kg) APAP 10-15 IBU 7.5 Naproxen sodium (>12yoa) 220-440mg q8-12hrs (MAX 660 mg/d) Aspirin 10-15 Adult APAP 325-1000mg (4000mg) IBU 200-400mg (1200mg) Aspirin 650-1000mg (4000mg) Mg salicylate 650mg q4 or 1000mg q6 (4000mg) Notes: -Avoid salicylates/NSAIDS if asthma and nasal polyps, chronic/recurrent GI ulcers, gout, coagulation disorders/anticoagulant therapy, HBP, CHF, kidney disease, aspirin allergy - Drug interx Asprin INCREASES valproic acid concentration (use naproxen instead) NSAIDS INCREASES digoxin concentration NSAIDS/salicylates inhibit antihypertensive meds and may cause hyperkalemia with ACEi and K sparing diuretics NSAIDS/salicylates INCREASES MTX Salicylates and sulfonylureas: hypoglycemia -alternative meds: butterbur 50+mg/d for migraine: belching, avoid during pregnancy/lactation, avoid with UPA products feverfew-migraine: rebound, mouth ulceration, anticoagulant effect peppermint oil-tension HA: irritation, avoid during pregnancy/lactation CoE Q10 150mg/d for migraine: avoid during pregnancy/lactation, GI disturbances Mg 20mmol/d for prevention of migraine, IV during acute attack: diarrhea, GI Riboflavin 400mg/d for migraine frequency: diarrhea, polyuria
develop tight band of muscle tissue ³trigger point´.8 F (1 C) in adults. weakness. eosinophilia) Usually happens week after. happens if do not Mobilize area after rest/healed Ice <15min 3-4x/d closest to time of injury. thioxanthenes)
MUSCULOSKELETAL INJURIES AND DISORDERS Exclusion Criteria: Moderate/severe Persist >2wks (7days after tx) Increased intensity or change in character Pelvic/abdominal other than dysmenorrhea N/V/fever or other s/s system infection/disorder Visually deformed joint. drop things *sx persist during sleep OA: pain does not measure damage Hip and knee: APAP 1st line Guarding: overly contracted. butyrophenones. anticholinergic: Decrease sweating [decrease heat dissipation] Sympathomimetics (amphetamines.5-98. heat pad.2 C (set point: physiologic/behavioral mechanisms NOT activated) Peak temp 4pm-6pm. metabolic acidosis Drug induced hyperthermia 102-104 F ( 38. urticarial.48 C) in children Phenothiazines. 48 hrs if vaccine-induced Hyperpyrexia: >106 F 41.58 F (1.cocaine. pronounced in children) Variation 1. vasoconstriction reduces vascular clearance of inflammatory mediators Heat 15-20min 3-4x/d 48+h AFTER injury or will exacerbate vascular leakage and tissue damage Use as warm wet compress. 2. incontinence. abnormal body movement. limb weakness.8-40 C).8 C Hyperthermia: malfunctioning of normal thermoregulatory process at hypothalamus Malignant hyperthermia >104 F (40 C).FEVER Exclusion Criteria: Notes: Fever definition: 100 F. high/low BP. 37. TCA. epinepheine): vasoconstriction [heat dissipation] Thyroid hormones: increase metabolic rate [increase heat generation] Neuroleptic Malignant Syndrome: high temp. 36.9 F. tachycardia. sweating. as high as 108 F Most common mechanism is hypersensitivity (rash. altered consciousness. muscle rigidity. muscle rigid.4-37. fracture 3rd trimester of pregnancy <2yoa Notes Sprains (ligaments) Grade I: excessive stretching Grade II: partial tear Grade III: complete tear Carpal tunnel syndrome: sense of heat/cold/swollen when not.1 C results in mental and physical consequences Avg temp 97. YOUNG MALE on neuroleptic meds (phenothiazines. Do NOT use with topical agents or broken skin Heat wraps should be worn over clothing if 55y and NOT during sleep
. water-bottle. Lowest 6am (consistent rhythm after 2 yoa. abnormal movement.
25% MOA: deplete substance P (slow/unmyelinated type C neuron.5-5% Ammonia water 1-2. released In response to endogenous stress or exogenous trauma/injury Capsaicin selective for process centers in type C fibers in skin DOA: 4-6h. delay 4-6wks Regular use 3-4x/d to keep pain from returning.25-16% >1% anesthetic 1.apply up to 3-4x/d up to 7 days nerve stimulation vs. LETHAL in children 5ml of 20% (resp dep. drop BP/HR.025% -> cough
COUGH Exclusion criteria: FDA ADVISES AGAINST Pharmacological tx for <2 yoa****** (labeling <4) Thick yellow sputum/green phlegm Fever >101.25% counterirritant
prolong PT with warfarin tonic-clonic after 10min. recontinue ok Tachyphylaxis No action on BV so not rubeficient Reduce pain NOT inflammation Penetration enhancer *** >1% ->neurotoxicity and hyperalgesia *** >0.25-1%
inactive topically. status epilepticus) LETHAL 2g
Vasodilator Histamine dihydrochloride 0.activation by menthol and capsicum produces heat Counterirritant. depression of pain Indicated for temporary relief of minor aches/sprains of muscle/joints FDA approved Cat I Rubefacients Allyl isothiocyante 0.025-0. pain relief in 14days.6 C) Unintended weight loss Drenching nighttime sweats Hemoptysis
.1% Methyl nicotinate 0.5% Methyl salicylate 10-60% Turpentine oil 6-50% Cooling Camphor 3-11% Menthol 1.TRVP1 receptor.5 F (38. syncope
Irritant w/o rubefaction but equipotent Capsicum/Capsicum oleoresin/capsaicin 0.025-0.
Subacute 3-8 wks. stomach discomfort. in breast milk so may cause excitation and irritability and decrease flow Protussive (Expectorants) Guaifenesin Indicated for sx relief of ACUTE and INeffective productive cough (thins mucus inc productiveness)
. PEDS 6-12y ½. subacute postinfectious cough Naproxen may reduce viral cough (increased upper airway afferent nerve sensitivity) Guaifenesin not recommended for any indication Honey.botulism in <1y Codeine 10-20mg q4-6h (120mg). DOA SE drowsiness. constiplation LETHAL DOSE 0. 2-5y 1mg/kg/d in 4 divided acts centrally on medulla to increase cough threshold well absorbed orally. expulsive Acute (usually upper. hypotension. stenosing PU. (codeine/DM ineffective) Codeine/DM. sedation. hyperthyroidism.short sx relief of acute/chronic bronchitis. 15-30min onset. 2-5y 2. nervous. chronic 8+wks Re-evaluate 7 days Dry cough. psychosis/mania Blocks serotonin re-uptake (MAOi combination within 14 days ->serotonin syndrome: inc BP. elevated intraocular pressure. in breast milk but still compatible AAP Dextromethorphan 10-20mg q4h or 30mg q6-8h (120mg). hyperpyrexia. constipation Overdose. hepatic metabo paradoxical excitability in children and elderly SE drowsiness.5mg Centrally. sx prostatic hypertrophy. blurred vision. excitation. CV disease. myoclonus) Pregnancy category C. asthma. unknown if in breast milk and no recommendations Diphenhydramine HCl 25mg q4h (150mg). cardiopulmonary collapse CI: codeine hypersensitivity. urinary retention. viral) <3weeks.antitussive (central acting) American College of Chest Physician cough guidelines 2006 Viral URTI. 1st gen only. 4-6hr DOA hepatic metabo into morphine SE: N/V/dizziness. 9. 19mg. respiratory depression. bladder-neck obstruction. N/V. compressive. HTN CI hypersensitivity Pregnancy category B. drowsiness.5-5mg q4h or 7. similar indication. nonselective (heavy sedation/anticholinergic) well absorbed. irritability. restlessness. CNS stimulation (hallucination/convulsions) Caution: narrow angle glaucoma.confusion. PEDS 6-12y ½. premature birth Pregnancy category C (resp dep). COPD. discoordinated. arrhythmia. chronic bronchitis) Foreign object aspiration Drug associated cough (ACEi) Persist >7 days Worsens or new sx with self-tx Notes: 3 phases: inspiratory. CHF. medulla to increase cough threshold. onset. depression Abused for phencyclidine-like euphoric effect.5 q6-8h (30mg) Equipotent to codeine. 15min onset.5-1g. dryness Overdose CNS depression. severe N/V. pyloroduodenal obstruction.use combo 1st gen antihist with decongestant.Hx/Sx chronic underlying related disease (asthma. PEDS 6-12y ½ adult. 2-5y ¼ citrate 38mg. LRTI. resp dep.
allergies.7-5. PEDS 6-11y ½. drowsiness. stomach pain Topical antitussives Camphor 4.Little data supports efficacy esp at non-Rx dosage SE N/V/D. NOT for <6y Pseudoephedrine 60mg q4-6h (240mg). present 16-18days in nasopharynx Viral infection ends when enough neutralizing antibodies IgA and IgG leaked into mucosa RF smoking. dense population. headache. menthol & camphor (efficacy not well documented) Benzocaine Diclonine HCl Exclusions: Fever 101. old age <9mos hypersensitivity Notes Upper respiratory: pharynx.6-2.4mg). chronic (1+month) stress
. COPD.2% menthol Lozenges 5-10mg menthol Local anesthetic sensation and sense of improved air flow. nasopharynx. rash. stimulate sensory nerve endings in nose and mucosa Little data supporting efficacy LETHAL: 4 teaspoons of 5% camphor ingestion by children
COLDS Nasal decongestants Phenylephrine HCl 10mg q4 (60mg). CHF) Immunosuppressed Frail. less diverse social network. PEDS 6-11y ½ . nose. sedentary. paranasal sinuses Peak viral conc 2-4days.2% camphor or 3. cavernous sinusoids. local antiseptic cetylpyridinium chloride or hexylresorcinol. PEDS ½ Local anesthetics q 2-4h.5 (38.8% (both only FDA-approved) Steam inhalants 6.6) Chest pain SOB Worsening or additional sx during tx Underlying chronic cardiopulmonary diseases (asthma. dizziness.3% and menthol 2.6mg q4h (62. 2-5y ¼ Phenyephrine bitartrate 15.
Complications sinusitis. tilt head side to side. salicylic acid.increase BP. sodium citrate. phenylephrine Propylhexedrine. phenylephrine. methyldopa. isocarboxazid. triclosan Direct acting on adrenergic receptors: phenylephrine.6g/d. drop. sniff deeply. naphazoline. mid ear infections. bronchitis. and benzalkonium chloride preservative 3-5days is current accepted duration of therapy
Pump nasal sprays: prime before 1 use. GI Pseudoephedrine well absorbed. gently insert. tetrahydrozoline Intermediate: xylometazoline Long: oxymetazoline Systemic decongestants metabolized by COMT and MAO in mucosa. gently insert. lie on bed with head tilted back over side of bed. benzalkonium chloride.5-2h Non-Rx decongestants not FDA approved for sinusitis Rhinitis medicamentosa contributed by short-acting. pyroglutamic Acid.decrease elimination of pseudoephedrine (potassium acetate. slow acting but longest DOA Mixed: pseudoephedrine and phenylephrine Ophthalmic: naphazoline. 9g/month per patient FDA 2007 petition PE 10mg to 25mg q4h Decongestants *Overdose: excessive CNS stimulation. do NOT rinse dropper Coricidin HBP is marketed for HTN patients. oxymetazoline. bacterial pneumonia. press once Nasal inhalers: warm in hand. procarbazine TCA. sodium bicarbonate. epinephrine. DISCARD after 2-3mos Nasal drops (preferred for small children): squeeze bulb to release med. lie for couple min. avoid xylometazoline and naphazoline Concomitant drug use with decongestants MAOi¶s. citric acid)
. asthma/copd Exacerbations Effective ingredients ethyl alcohol 62-95%. CV collapse. does NOT contain decongestant Pseudoephedrine sale limited to 3. oxymetazoline. levmetamfetamine. paradoxical CNS depression. coma -only supportive TX *SE: elevated BP. shock. sniff deeply while inhaling. liver. tilt head forward. potassium citrate. arrhythmia. decrease milk production. long duration. drink more water Oxymetazoline preferred (poor absorbtion) PE and pseudoephedrine compatible with breast-feeding. depletion-> tachyphylaxis). PE low F Both peak conc at 0. CNS stimulation *CI concomitant MAOi Pregnancy cat B/C. tranylcypromine. decrease decongestant activity Antacids/alkalinizers. furazolidone. lactate. tetrahydrozoline INS non-Rx decongestants Short-acting: ephedrine.increase BP Phenelzine. theoretically decrease fetal blood flow (Pseudoephedrine-abdominal wall defects in newborns). tetrahydrozoline Indirect: ephedrine (displace NE from storage vesicles. sodium acetate.
hotflash Zinc may block adhesion of rhinovirus to nasal epithelium. Loratidine.increased loratadine plasma concentration Theophylline >400mg increased cetirizine plasma concentration Complementary therapies Butterbur-hepatoxic and renal. restlessness. dry mouth. any other INFECTION undiagnosed/uncontrolled asthma. peak 1. increase activity of natural killer cells)
ALLERGIC RHINITIS Exclusions <12y pregnant/lactating non-allergic sx otitis media.decreased elimination with chlorpheniramine Ketoconazole. non-sedating. prophylaxis effective in marathon runners Larch arabinogalactan (probiotic. heart attack. cimetidine. 4g/d.N/V. stroke. aggravate immune disorders. bronchitis. decrease BP with dexchlorpheniramine Phenytoin.with antihistamines CNS depressants MAOis. erythromycin. peripherally selective Well absorbed. immunosupp with prolong use English Ivy. sinusitis. skin irritation Ephedra. GI Echinacea.Tachycardia. cetirizine elderly: Loratidine and IN cromolyn
. uterine contract. nasal sting/burn.5-3h CI in breast-feeding (otherwise take hs after last feeding) Pregnancy: IN Cromolyn(cat B) 1st line <12y: REFER. HTN.hepatoxic.insomnia.diarrhea.anticholinergic/CNS depressive. may inhibit viral replication by disrupting viral capsid SE headache. nasal tenderness. seizure Ginseng. COPD persistent/unresponsive to tx unacceptable SE Notes nd Antihistamine.2 gen. ANOSMIA Lozenges SE GI Vitamin C >2g/d high dose.
follow-up. gas chromatography/mass spectrometry to confirm Antibody binding proportional to concentration. partial immunoassay Detection in urine: Ethanol: 2-12h Propoxyphene: 6-48h
.nasal decongestant/ephedrine Opiates. enzyme immunoassay. promotions into sensitive positions Random testing to identify and discourage future use (impaired professionals in recovery) Universal testing in a workplace Screening test technologies: Radioimmunoassay.dextromethorphan or negative to other impairing products: morphine. florescence polarization immunoassay. methaqualone and phenobartbital 2-3 wks Amphetamines/secobarbital so quick may show up negative Reasons for drug testing: Pre-employment Appear high. involved in accident possibly caused by drugs Safety on-the-job Return to service physical exams.DRUG TESTING Drugs impairing in the workplace (in order of most to least): Alcohol > marijuana > cocaine > opiates > amphetamines/benzodiazepines/barbituates Drug tests do not measure level of intoxication or use patterns Immunoassay to screen out negative tests.oxycodone. possible similar substances may have false positive: Amphetamines. meperidine Benzoyl ecgonine is metabolite of cocaine only (novocaine argument) Sensitivity-how long drug/metabolites detectable Most drugs can be detected in urine for up to 3 days.
10d (daily). cocaine. PCP Signs of drug use parents should use: Low grades/poor school performancy Aggression. 20d (chronic) Phencyclidine: 14d Methaqualone: 2 wks PDT-90: marijuana.Amphetamine: 48h Opiates: 2d Methadone: 3 d Cocaine metabolite/benzoyl ecgonine: 2-4d Barbituates: 24h (short-acting). rebellion Excessive peer influence Lack of parental support/guidance Behavior problems at early age Alert to alcohol and other drug use
. 2-3wks (long-acting) Benzodiazepines: 3d-yrs Cannabinoids: 4-5d (moderate 4x/wk). opiates (heroin). methamphetamines.