EMERGENCY DRUGS USED IN ORAL SURGERY & COMMON DRUG INTERACTIONS IN ORAL SURGICAL PRACTICE

CONTENTS
* Introduction * Classification of the emergency drugs * Individual emergency drug * Drug interactions

EMERGENCY DRUGS USED IN ORAL SURGERY
1. Adrenaline bromide 2. Atropine 3. Dopamine 4. Metoclopramide 5. Phenaramine maleate 6. Hydrocortisone 7. Dexamethasone 8. Diazepam 9. Fortwin-pentazocin 10. Furosemide maleate 11. Pancuronium 12. Styptochrome 13. Ethamsylate 14. Ketorolac 15. Aminophylline 16. Succinyl choline 17. Dextrose 18. Sodium bicarbonate 19. Calcium gluconate 20. Chlorphenaramine

CLASSIFICATION
Emergency drugs
Injectables Non Injectables Oxygen Vasodilators Respiratory stimulants Anti Hypoglycaemic agents Bronchodilators Primary
advanced cardiac support

Secondary

Drug for life

1) 2) 3) 4)

Adrenaline Antihistamine Anti convulsant

1) 2) 3)

Analgesic Vasopressor

1) Lidocaine 2) Atropine

Corticosteroid 3) Sodium bicarbonate

Narcotic antagonist 4) Antihypoglycaemic

ADRENALINE
INTRODUCTION :
- It is an adrenergic drug. - It increases heart rate,force of contraction and cardiac output. - It constricts blood vessels. - It increases mean BP. - Potent bronchodilator - It causes mydriases in eye that is pupil dilatation.

INDICATIONS :
- Anaophylactic shock - In bronchial asthma - In cardiac arrest - With local anaesthesia - To control post extraction haemorrhage - To treat open angle glaucoma

CONTRAINDICATIONS - Hypersensitivity - Hyperthyroidism - Hypertension - Angina pectoris - Diabetes mellitus TRADE NAME : Adrenor, Asmotone DOSAGE : 0.2-0.5 mg s.c , 0.5 % aerosol in case of im /iv – in conc of 1:10,000 to 1:1,00,000 ADVERSE EFFECTS - Marked increase in BP - photosensitivity, skin rashes - palpitation, arrythmias -anginal pain, ventricular failure

ATROPINE
INTRODUCTION
- It is a parasympathetic drug -Anticholinergic action - Antispasmodic action - Antisecretory action - Anti muscarinic action - It causes tachycardia - Anti dote for organo phosphate poisoning.

INDICATIONS - Motion sickness
- Colics and dysmenorrhoea - Anti parkinsonism - Pre operatively to reduce secretions & salivation - In bronchial asthma - Severe sinus bradycardia

CONTRAINDICATIONS - Hypersensitivity to belladona alkaloid
- Glaucoma - Prostatic hypertrophy - Cardiac failure - Thyrotoxicosis

TRADE NAME : Atro, Tropine, Atropine sulphate DOSAGE : Children : oral – 0.2 mg/kg
inj --0.3-0.6 mg i.m Adults : 0.6- 2 mg/ml i.m

ADVERSE EFFECTS - Dry mouth, decreased salivation
- Decreased sweating - Constipation - Tachycardia, palpitations, arrythmias - Mydriasis and cycloplegia

DOPAMINE
INTRODUCTION - Potent sympathomimetic agent - Agonist for dopamine receptors in CNS,renal and other vascular beds - Agonist for beta adreno receptors in heart - At high doses it causes vasoconstriction - At low doses it causes increase in renal blood flow, GFR, and sodium excretion. INDICATIONS - Cardiogenic shock - Septic shock - Septicaemia - Congestive heart failure - Renal failure - Heart failure

CONTRAINDICATIONS - Atrial/venticular tachy arrythmias - Hyperthyroidism - Pheochromocytoma TRADE NAMES : Dopamine, Dopinga, Dopapins, Dopar, Dopat. DOSAGE : Children – 2-20 microgram/kg/min i.v Adults ADVERSE EFFECTS - Nausea , vomitting - Tachycardia - Palpitation - Anginal pain - Atopic beats -- 2-50 micrograms/kg/min i.v

METOCLOPRAMIDE
INTRODUCTION - It is a pro kinetic drug -- causes forward propulsion of contents of stomach
- Centrally acting dopamine antagonist - Acts on chemoreceptor trigger zone - Peripherally acts to enhance the effect of A-ch at muscarinic receptors in gut

INDICATIONS - As an anti emetic – in nausea, vomitting
post operative vomitting drug/disease induced vomitting radiation sickness morning/ motion sickness - Gastritis - Reflux oesophagitis - Gastroenterology

CONTRAINDICATIONS - Gastro intestinal perforation/ obstruction
- Epilepsy - Parkinsonism - Breast cancer

TRADE NAMES : Reglan, Perinorm, Metaclop, Emenil, Vominil DOSAGE : oral – 5-10 mg TDS
INJ. – 2 ml TDS

ADVERSE EFFECTS - Dizziness
- Diarrhoea - Trismus, - Tremors - Gynaecomastia, - Galactorrhoea

PHENARAMINE MALEATE
INTRODUCTION -It is an alkylamine derivative
- Antihistaminic - Anti cholinergic property - Anti muscarinic property - Central sedative property

INDICATIONS - In allergies – urticaria
itching angioedema dermatitis - Common cold - Motion sickness - Insect bite - To decrease the BP

CONTRAINDICATIONS -Hypersensitivity
-Acute porphyria

TRADE NAME : Avil, Avil Retard DOSAGE : Children-- syrup ------- 1-3 yrs : 2.5 ml TDS
3-12 yrs: 5 ml TDS Inj ------- 0.6 – 2 ml i.m OD/BD Adults -- oral ---- 25 – 50 mg TDS inj ---- 1.2 ml i.m TDS

ADVERSE EFFECTS - Abuse potential
- Dry mouth - Blurred vision - Constipation - Retention of urine

HYDROCORTISONE
INTRODUCTION - It is a glucocorticoid ( corticosteroid)
- It causes adreno pituitary axis suppression - They maintain fluid electrolyte balance - They maintain functional status of skeletal, muscles and nervous system

INDICATIONS
- Acute allergic reactions - Anaphylactic shock - Status asthmaticus - Addison’s disease - Rheumatoid arthritis - Pruritis - Tubercular meningitis - Infective eczema

CONTRAINDICATIONS - Neonates , infants
- Local/systemic infections - Herpetic/fungal keratitis - Cataract

TRADE NAMES : Corts, Lycortin, Primacort, Lutisoft cream, Neosporin – H DOSAGES :
Anaphylaxis – 100-150 mg/sec i.m 6 hourly Status asthmaticus – 100-200 mg i.v 6 hourly

ADVERSE EFFECTS - Hyperglycaemia
- Hyperkalemia - Delayed wound healing - Water and sodium retention - Osteoporosis - Calcium deposition

DEXAMETHASONE
INTRODUCTION
- Corticosteroid derivative - Long acting, very potent, highly selective glucocorticoid - It causes marked pituitary adrenal suppression - Anti-inflammatory and anti-allergic properties

INDICATIONS - Allergic conditions
- Overwhelming infection - Inflammation in eye disorder - Shock due to trauma - Rheumatoid arthritis - Adjuvant anti emetic - Adrenal crisis

CONTRAINIDICATIONS -Diabetes mellitus - Congestive heart failure - Renal failure - Tuberculosis - Pyschosis - Osteoporosis TRADE NAME : Dexona, Dexavin, Decadan DOSAGES : Children - 0.1 – 0.5 mg/kg/fay Adults ADVERSE EFFECTS - Hyperglycaemia, glycosuria - Delayed wound healing - Osteoporosis - Cushing syndrome - 4-20 mg/day s.c/i.m/i.v

DIAZEPAM
INTRODUCTION - Prototype of benzodiazepine
- Sedative hypnotic action - Skeletal muscle relaxant - Anti convulsant actiond - Potentiates the neural GABA mediated inhibition in CNS

INDICATIONS - Anxiety, tension
- Psychosomatic and behaviour disturbances - Status epilepticus - Tetanus -Dysmenorrhoea - Termination of prolongd seizure - Local anaesthetic seizure

CONTRAINDICATIONS - Hypersensitivity to benzodiazepines
- Acute narrow angle glaucoma - Myasthenia gravis

TRADE NAMES : Calmpose, Calmod, Placidox DOSAGES : Oral - 5-20 mg/day i.m in divided doses
inj – 10mg/2ml i.v

ADVERSE EFFECTS - Respiratory depression
- GIT disturbance - Drug dependance and abuse

FORTWIN – PENTAZOCINE
INTRODUCTION - Opioid analgesic
- Morphine like action - It has agonist – antagonist type action that is weak antagonist and marked agonist actions

INDICATIONS - Chronic , recurrent, moderate to severe pain which is
assosciated with - - - surgery trauma fractures labour pains burns cancer

CONTRAINDICATIONS
- Children below 12 years - Hypertensives - Ischaemia - Myocardial infarction

TRADE NAMES : Fortwin, Fortagesic, Pentazocin, Pentawin DOSAGES :
30 – 60 mg / ml i.v 3-4 hourly

ADVERSE EFFECTS - Nausea, vomitting
- Euphoria - Respiratory depression - Hypertension, tachycardia, palpitation - Withdrawl syndrome (rarely)

FUROSEMIDE
INTRODUCTION
- It is a diuretic - It causes loss of Nacl, Ca, K, Mg, PO 4, Na, water loss - It causes pooling of blood in peripheral deep veins - This effect occurs before the diversion and is important for the treatment of left ventricular failure and pulmonary edema

INDICATIONS - Oedema in congestive heart failure, hepatic disease,
renal disease and pulmonary oedema - Hypertension - To treat hypercalcaemia - To treat drug overdose ------ by inducing forced diuresis and facilitate rapid elimination of drug

CONTRAINDICATIONS
- Hypovolaemia - Hypotonia - Hepatic coma - Renal failure with anuria and potassium defenciency

TRADE NAMES : Lasix, Frusenex, Salinex DOSAGES : Children : 20 – 40 mg / day
Adults : Oral -- 40 – 100 mg Inj -- 20 mg / 2 ml inj

ADVERSE EFFECTS - Fluid and electrolyte imbalance
- Visual impairment - Hearing impairment, deafness - Muscle cramps - Paraesthesia

PANCURONIUM BROMIDE
INTRODUCTION
- Long acting, non depolarizing, peripherally acting skeletal muscle relaxant - Competitive antagonist of acetyl choline at neuro muscular junction

INDICATIONS
- Long acting skeletal muscle relaxant in surgical anaesthesia - Assisted ventilation

CONTRAINDICATIONS - Hypersensitivity
- Inadequate general aneasthesia - Depressed ventilation

TRADE NAMES : Pavulon, Fancuron DOSAGES : 2 mg/ ml i.v ADVERSE EFFECTS - Hypotension
- Bronchospasm - Reduction in GI motility - Wheel and flare reactions at site of injection

STYPTOCHROME
INTRODUCTION - It is a haemostatic agent
- It is a preparation of adrenochrome mono semi carbazone - It exerts haemostatic action by reducing capillary fragility - It prevents microvessel bleeding

INDICATIONS - Epistaxis
- Retinal haemorrhage - Secondary haemorrhage from wounds - Haematuria - Menorrhagia

CONTRAINDICATIONS - Hypersensitivity

TRADE NAMES : Styptochrome, Cadisper – c, Styptocid DOSAGES : Pre operatively 2-6 ml at suitable intervals Postoperatively 1-2 ml every 2 hours

ETHAMSYLATE
INTODUCTION - It is a haemostatic agent
- It decreases capillary bleeding when platelets are adequate - It inhibits PGI 2 production - It corrects abnormal platelet function

INDICATIONS - Epistaxis
- After tooth extraction - Hematuria - Malena - After abortion - Menorrhagia - Post surgical conditions

CONTRAINDICATIONS
- Hypersensitivity - Porphyria - History of thrombocytopenia purpura haemophillia

TRADE NAMES : Ethamsyl, Hemsyl, Stat DOSAGES : Oral -- 500 mg tab post operatively
inj -- pre operatively - - 1-2 ampules 1 hour before surgery postoperatively - - 1-2 ampules 4 to 6 hourly

ADVERSE EFFECTS - Nausea , headache
- Skin rashes - Fall in BP after i.v injection

KETOROLAC
INTRODUCTION - It is a non steroidal anti inflammatory drug (NSAID)
- It is a pyrrolo-pyrrole derivative of non selective cox inhibitor (conventional NSAID) - It is a potent analgesic, antipyretic, and anti inflammatory agent - It relieves pain by peripheral mechanism

INDICATIONS - Management of acute pain
- Post operative and acute musculoskeletal pain - Renal colic - Migraine - Pain due to bony metastasis - Post operative --inflammation itching allergy

CONTRAINDICATIONS - Hypersensitivity - After ocular surgery - Peptic ulcer -Coagulation disorder TRADE NAMES : Ketorol, Ketotifen, Ketanov, Cadolac DOSAGES : Oral - - 20 – 40 mg/day Inj - - 4 – 6 ml i.m ADVERSE EFFECTS - Gastric disturbances - Ocular irritation - Wound healing abnormalities - Superficial keratitis

AMINOPHYLLINE
INTRODUCTION
- It is a bronchodilator - Stable mixture of theophylline and ethylene di amine - Directly relaxes smooth muscles of bronchi and lungs - Stimulates CNS - induces diuresis - Increases gastric acid secretion

INDICATIONS - Reversible airway obstruction
- Severe acute asthma

CONTRAINDICATIONS
- Hypersensitivity - Hypertension - Peptic ulcer

TRADE NAMES : Aminophylline, Deriphylline, Minophyl DOSAGES : Oral - - 200-300 mg 3-4 times a day
Inj - - 200-500 mg slowly over 20 minutes

ADVERSE EFFECTS - Tachycardia
- GI disturbance - Convulsions - Severe hyperventilation

SUCCINYL CHOLINE
INTRODUCTION
- It is an ultra short actiong ,peripherally acting , neuro muscular blocking skeletal muscles relaxant

INDICATIONS
- During General Anaesthesia - During seizures - Respiratory arrest during tracheal intubation

CONTRAINDICATION - Glaucoma
- Myasthenia gravis - In case of burns - History of malignant hyperthermia

TRADE NAMES : Scoline, Scolax, Succinyl chloride, Succin inj DOSAGES : 20- 100 mg ADVERSE EFFECTS - Hypertension - Hyperkalemia - Hyperthermia - Raised intra cranial pressure - Muscle pain - Respiratory depression

DEXTROSE
INTRODUCTION
- It is a hyperglycemic agent - It rapidly elevates the blood glucose level by mobilizing hepatic glycogen and converting it to glucose

INDICATIONS
- Severe hypoglycaemia - Diagnostic tool in unconsciousness and seizures of unknown origin - Cardiogenic shock (rarely)

CONTRAINDICATIONS - Chronic hypoglycaemia
- Hyperglycaemia - Starvation states

TRADE NAMES : Glucagon DOSAGES : 1md dry powder + 1 ml diluent (50 ml bottle for emergency kit – 50 % dextrose) ADVERSE EFFECTS - Nausea, vomitting - Allergic reaction - Tissue necrosis if there is infiltration

SODIUM BICARBONATE
INTRODUCTION
- It is an antacid n used to correct acidosis assosciated with hypoxia cardiorespiratory arrest metabolic acidosis - Adequate ventilation is necessary whenever sodium bicarbonate is given because carbon di oxide is produced in this procedure

INDICATIONS - Reversal of metabolic acidosis occurring during anaerobic metabolism in
cardiopulmonary arrest - Calcium and vitamin D defeciency states - Pregnancy and lactation - Bladder washes\ - Auricular lavage - Bronchial lavage

CONTRAINDICATIONS
- In alkalosis - Respiratory depression - Hypocalcaemia - Sodium overload

TRADE NAMES : Sodium bicarbonate DOSAGES : 90 – 180 mEq / lit ADVERSE EFFECTS - Metabolic alkalosis with impairment of release of oxygen from Hb
- Sodium and water overload - Local pain - Venous irritation

CALCIUM GLUCONATE
INTRODUCTION - Essential for cardiac function muscle contraction nerve activity and blood coagulation - To maintain standard integrity of all membranes - It causes neuro transmitter release DEFENCIENCY SIGNS AND SYMPTOMS : - Osteoporosis - Pathologic fracture - Brittle nails and hair

INDICATIONS
ORAL INJECTIONS

Mild hypocalcaemia hypocalcaemia Growing children Pregnancy Lactation Post menopausal women of Rickets Osteomalacia

Severe

Hypoparathyroidism Hyperkalemia Cardiac arrest

Every fourth bottle blood transfusion

CONTRAINDICATIONS
- Renal calculi - Hypophosphataemia - Hypercalcemia - Hypoparathyroidism

TRADE NAMES : Calciium sandoz, Calcid, Calcibom DOSAGES : Oral -- 1 gram
Inj -- 10 % inj

ADVERSE EFFECTS - Constipation
- Abdominal discomfort - Bloating - Dyspepsia -Excess gas

Common drug interactions in oral surgical practice
Drug Interacting Drug Drug Interaction
Increased drowsiness and sedation Increased risk of bleeding Premature release of aspirin Increased risk of gastroitestinal bleeding Increased risk of methotrexate toxicity Potentiates hypoglycaemic drugs effect Increased effect of antiepileptics

1)Antihistamine CNS depressants 2) Salicylates
1) 2) 3) 4) 5) 6)

Anticoagulants Antacids Corticosteroid Methotrexate Oral hypoglycaemics Phenytoin

3) Atropine

1) Alcohol

Impaired motor performance and increased drowsiness. Depressed CNS Depressed CNS Retarded effect of drug Increased carbamazepine isoniazid plasma level resulting in sedation

4) Carbamazepine 1) Alcohol 2) Barbiturates, doxy cycline oral hypoglycemics steroids 5) Corticosteroids 3) Erythromycin 1) Anti diabetic drugs

Corticosteroids may exacerbate diabetic state by hypoglycemic action Antagonism due to fluid retention Increased anti-inflammatory response to 2) Anti hypertensivestopical steroids 3) Oral cotraceptives

6) Cotrimoxazole 1) Diuretics 2) Anti coagulants, anti epileptics, oral hypoglycemics 7)Diazepam 8) Doxy cycline CNS depressants 1) Penicillin 2) Barbiturates, antiepileptics

Increased risk of thrombocytopenia in elderly Potentiate action of these agents

Intensified sedative effects Reduced effect of penicillin Possiblility of reduced plasma concentration of Doxy cycline. Antagonism, therefore alcohol should be avoided Incereased risk of toxicity of phenytoin Potentiated anticoagulant effect Reduced plasma level of metronidazole

9) Metronidazole 1) Alcohol 2) Antiepileptics 3) Anticoagulants 4) Barbiturates

10)Penicillin

oral Contraceptives Increased bleeding, possibly with contraceptive failure

11)Tetracyclines

Oral contraceptives Increased bleeding due to contraceptive faliure Oral hypoglycemic Increased hypoglycemic effect Incerased methotrexate toxicity Methotrexate

References :
1. Essentials of medical pharmacology (By K.D.Tripathi). 2. A text book of pharmacology (Satoskar). 3. A text book of Oral and Maxillofacial surgery (By B. Srinivasan). 4. Contemporary Oran and Maxillofacial
Surgery

(By Peterson).

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