Domina Petric MD Emergency medicine physician bag A
Domina Petric, MD Emergency medicine physician bag
A 6/4/2021 Emergency medicine 2
Adrenalin (epinephrine) Indications: • anaphylaxis, anaphylactic shock • cardiac arrest 6/4/2021 Emergency medicine 3
Anaphylaxis • flushing, apprehension • syncope, tachycardia • thready or unobtainable pulse associated with hypotension • convulsions • vomiting, diarrhea and abdominal cramps • involuntary voiding, airway swelling • laryngospasm, bronchospasm 6/4/2021 Emergency medicine 4
Anaphylaxis • pruritus, urticaria, angioedema • swelling of the eyelids, lips and tongue 6/4/2021 Emergency medicine 5
Adrenalin dosage in anaphylaxis One ampulla: 1 m. L/1 mg (1: 1000) 6/4/2021 For iv. application: 1: 10 000 (diluted with saline, usually 910 m. L) Emergency medicine 6
Adrenalin dosage in anaphylaxis Children under the age of 6 years 0, 15 m. L (150 mcg) im. Children age 6 -12 years 0, 3 m. L (300 mcg) im. Children older then 12 years 0, 5 m. L (500 mcg) im. Adults 0, 5 m. L (500 mcg) im. Adrenalin im: 1: 1000 Repeat if there is no clinical improvement after 5 minutes. In more severe cases: Children under 0, 3 m. L (0, 3 mg or the age of 12 years 300 mcg) iv. Older children and adults 6/4/2021 0, 5 m. L (0, 5 mg or 500 mcg) iv. Emergency medicine Adrenalin iv: 1: 10 000 Repeat if there is no clinical improvement after 5 -10 minutes. 7
Adrenalin dosage in cardiac arrest Children under the age of 12 years Older children and adults 0, 1 -0, 3 m. L (0, 01 -0, 03 mg or 10 -30 mcg) diluted 1 m. L (1 mg) diluted with saline Third, fifth, seventh reanimation cycle. . . 6/4/2021 Emergency medicine Adrenalin for iv. application is diluted with saline in ratio 1: 10 000! Repeat if there is no clinical improvement every 3 minutes (once in two reanimation cycles). 8
Common adverse reactions • • 6/4/2021 anxiety, apprehensiveness, restlessness tremor, weakness, dizziness sweating, palpitations pallor nausea and vomiting headache respiratory difficulties Emergency medicine 9
Precautions for the patients with: Arrhytmias can occure: ventricular fibrillation! 6/4/2021 • • • heart disease hypertension hyperthyroidism Emergency medicine 10
Aminophylin Indications: • severe acute bronchospasm in allergic reactions • chronic obstructive pulmonary disease 6/4/2021 Emergency medicine 11
Dosage • example: ampulla 10 m. L/250 mg Dose is 5 mg/kg slowly within 20 minutes! • 1 mg contains 0, 04 m. L • Dose in m. L: 5 mg x BW (kg) x 0, 04 m. L 70 kg patient: 5 mg x 70 kg x 0, 04 m. L • Result: 14 m. L 6/4/2021 Emergency medicine 12
Contraindications: arrhytmias (supraventricular especially) acute miocardial infarction porphyria 6/4/2021 Emergency medicine 13
Side effects: • • • 6/4/2021 arrhytmias convulsions hypotension nausea vomiting fear Emergency medicine 14
Amiodaron (Cordarone ampulla 3 m. L/150 mg) Cardiac arrest (ventricular fibrillation, ventricular tachycardia without pulse): • 300 mg iv. bolus diluted in 20 m. L of 5% glucose (third cycle of reanimation), two ampulla needed (6 m. L) • repeat for 10 to 15 minutes in doses of 150 mg iv. bolus (fifth cycle of reanimation), one ampulla (3 m. L) 6/4/2021 Emergency medicine 15
Amiodaron (Cordarone ampulla 3 m. L/150 mg) Hemodinamically stable ventricular tachycardia: 6/4/2021 Emergency medicine • 150 mg iv. diluted with • 20 m. L 5% glucose slowly within 10 minutes 16
Amiodaron (Cordarone ampulla 3 m. L/150 mg) Medicamentous conversion of acute atrial fibrillation with fast ventricular response if there is ORGANIC HEART DISEASE: • 5 mg/kg iv. within 20 minutes up to two hours diluted in 5% glucose • If ampulla 3 m. L/150 mg, 1 mg is 0, 02 m. L • 70 kg patient: 5 mg x 70 kg x 0, 02 m. L = 7 m. L 6/4/2021 Emergency medicine 17
Medicamentous conversion of atrial fibrillation is possible only if onset was within 48 hours! 6/4/2021 Emergency medicine 18
Contraindications: cardiogenic shock sinus bradycardia AV block of second and third degree 6/4/2021 Emergency medicine 19
Side effects: • • • 6/4/2021 hypotension bradycardia AV block allergic reaction ventricular tachycardia ventricular fibrillation Emergency medicine 20
Atropin-sulfate (ampulla 1 m. L/0, 5 mg or 1 m. L/1 mg) Symptomatic bradycardia (heart rate less then 40 bmp) with systolic blood pressure less then 90 mm. Hg: • 0, 5 mg iv. every 5 minutes, maximum dose is 3 mg Organophosphates poisoning: • 2 -5 mg iv. with titration 6/4/2021 Emergency medicine 21
Contraindications: atrial fibrillation and undulation glaucoma (relative contraindication) 6/4/2021 Emergency medicine 22
Side effects: • • • 6/4/2021 mydriasis tachycardia headache dry mouth ventricular tachycardia ventricular fibrillation Emergency medicine 23
6/4/2021 Emergency medicine 24
Biperiden (Akineton ampulla 1 m. L/5 mg) Extrapyramidal symptoms: • 2, 5 -5 mg (0, 5 -1 m. L) im. or slowly iv. 6/4/2021 Emergency medicine 25
Other indications: • • • 6/4/2021 nicotin poisoning (10 mg im. ) organophosphates poisoning rigor and tremor in Parkinson´s syndrome Emergency medicine 26
Dosage for children Children under the age of 1 year Children age from 1 to 6 years Children age up to 10 years 6/4/2021 1 mg (0, 2 m. L) iv. slowly 2 mg (0, 4 m. L) iv. slowly 3 mg (0, 6 m. L) iv. slowly Emergency medicine 27
Contraindications: • narrow angle glaucoma • gastrointestinal obstructions (ileus, megacolon) • urin retention • prostate adenoma 6/4/2021 Emergency medicine 28
Side effects • • 6/4/2021 tachycardia dizziness weakness restlesness fear dry mouth vision problems gastrointestinal problems Emergency medicine 29
D 6/4/2021 Emergency medicine 30
Dexamethason (Ampulla 1 m. L/4 mg) Antiedematous therapy of the brain: • start dose is 10 mg iv. (2, 5 m. L or two and a half ampulla) Chronic extended allergic reactions: • 0, 4 -20 mg im. or slowly iv. 6/4/2021 Emergency medicine 31
Contraindications: peptic ulcer tuberculosis other difficult and poorly controled infections 6/4/2021 Emergency medicine 32
Side effects: • • 6/4/2021 arterial hypertension gastrointenstinal problems headache dizziness Emergency medicine 33
Diazepam (Ampulla 2 m. L/10 mg or 1 m. L/10 mg) Acute psychosis, acute psychoorganic reaction or acute reaction on organic disease: • 10 mg im. or very slowly iv. Convulsions: • 5 -10 mg slowly iv. • dose can be repeated after 10 -15 minutes • maximum dose is 30 mg 6/4/2021 Emergency medicine 34
Convulsions in children • 0, 2 or 0, 3 mg/kg iv. • 1 mg x number of years + 1 • Example: child is 5 years old, ampulla 2 m. L/10 mg • 1 mg x 5 years + 1 = 6 mg (1, 2 m. L) iv. • If ampulla 1 m. L/10 mg: 6 mg (0, 6 m. L) iv. 6/4/2021 Emergency medicine 35
Diklofenac (Voltaren 3 m. L/75 mg) Musculosceletal pain, renal and biliary colics: 6/4/2021 • 75 mg (3 m. L) im. (deep intramuscular injection) Emergency medicine 36
Contraindications: hypersensitivity on acetylsalicylic acid 6/4/2021 Emergency medicine active peptic ulcer 37
Side effects: • nausea • gastrointestinal bleeding • peripheral oedemas 6/4/2021 Emergency medicine 38
F 6/4/2021 Emergency medicine 39
Flumazenil (Anexate ampulla 1 m. L/0, 5 mg) Benzodiazepines poisoning with breathing depression: • start dose is 0, 2 mg iv. (0, 4 m. L) iv. within 15 seconds • after 45 seconds, if patient is unconscious, another dose of 0, 2 mg • third and other doses are given in intervals of 1 minute • maximum dose is 1 mg 6/4/2021 Emergency medicine 40
Contraindications: • hypersensitivity on benzodiazepines or flumazenil • tricyclic antidepressants poisoning • raised intracranial pressure • epilepsy (chronic therapy) 6/4/2021 Emergency medicine 41
Side effects: • • 6/4/2021 nausea vomiting flushing restlesness confusion transitional arterial pressure elevation convulsions rarely Emergency medicine 42
Furosemid (Fursemid ampulla 2 m. L/20 mg) Acute left heart decompensation and pulmonary oedema development: 20 -100 mg iv. (2 -10 m. L) 6/4/2021 Emergency medicine 43
Contraindications: dehydratation hypokalemia hepatic coma 6/4/2021 Emergency medicine 44
Side effects: hypokalemia hypotension dehidratation 6/4/2021 Emergency medicine 45
G 6/4/2021 Emergency medicine 46
Glucagon (1 mg) Hypoglycemia with altered consciousness or coma: • 1 mg sc. , im. or iv. 6/4/2021 Emergency medicine 47
Contraindications: hypersensitivity pheochromocytoma insulinoma 6/4/2021 Emergency medicine 48
Side effects: • • • 6/4/2021 nausea vomiting hypersensitivity reactions hypokalemia transitional tachycardia Emergency medicine 49
Glucose (Glucosum 50% ampulla 10 m. L) Hypoglycemia: • start with 10 -50 m. L of >20% glucose iv. in bolus • continue with infusion of 10% or 5% glucose solution iv. infusion Children only 10% glucose: • 10 -15 m. L/kg of 10% glucose iv. infusion 6/4/2021 Emergency medicine 50
There are no absolute contraindications for glucose application! 6/4/2021 Emergency medicine 51
Side effects: • • • 6/4/2021 electrolytes imbalance hypokalemia hypomagnesemia hypophosphatasia venous obliteration Emergency medicine 52
H 6/4/2021 Emergency medicine 53
Haloperidol (Haldol ampulla 1 m. L/5 mg) Agitation, aggressiveness, hyperactivity in the patient with acute psychosis: • 2 -10 mg im. (dose can be repeated after one hour if necessary) • maximum dose is 20 mg Vomiting and nausea associated with malignant disease: • 0, 5 -2 mg (0, 1 -0, 4 m. L) im. 6/4/2021 Emergency medicine 54
Contraindications: • coma • acute poisoning with alchohol, antidepressants, neuroleptics, sedatives • central nervous system diseases with pyramidal and extrapyramidal symptoms 6/4/2021 Emergency medicine 55
Side effects: • • 6/4/2021 extrapyramidal symptoms depression sedation headache dizziness convulsions tachycardia hypotension Emergency medicine 56
6/4/2021 Emergency medicine 57
Ketoprofen (Ketonal ampulla 2 m. L/100 mg) Moderate to severe musculosceletal pain, renal and biliary colics: 6/4/2021 • 100 mg im. Emergency medicine 58
Kloropiramin (Synopen ampulla 2 m. L/20 mg) Acute allergic reaction, anaphylactic shock: • 20 mg im. or slowly iv. 6/4/2021 Emergency medicine 59
Contraindications: • • 6/4/2021 hypersensitivity epilepsy pregnancy and lactation not for babies and very small children Emergency medicine 60
Side effects: • • • 6/4/2021 coordination problems sedation fatigue dry mouth gastrointestinal problems Emergency medicine 61
L 6/4/2021 Emergency medicine 62
Lidocaine (2% lidocaine ampulla 2 m. L/40 mg and 5 m. L/100 mg) Antiarrhythmic drug (for example haemodynamically stable ventricular tachycardia): • 50 -100 mg iv. within 2 -3 minutes • bolus injection after 5 minutes if necessary • maximum dose 200 -300 mg within one hour 6/4/2021 Emergency medicine 63
Contraindications: AV block of second and third degree 6/4/2021 Adam-Stokes syndrome Emergency medicine 64
Side effects: • • • 6/4/2021 convulsions slurred speech tremor diplopia transitional amaurosis tinnitus hypotension bradycardia arrhythmias • • • dyspnoea bronchospasm vomiting nausea rash urticaria Emergency medicine 65
M 6/4/2021 Emergency medicine 66
Metildigoxin (Lanitop ampulla 2 m. L/0, 2 mg) Chronic atrial fibrillation with fast ventricular response: • 0, 2 mg iv. 6/4/2021 Emergency medicine 67
Metamizole (Analgin, Alkagin ampulla 5 m. L/2, 5 g) Stabbing pain: • 1, 0 -2, 5 g (2 -5 m. L) slowly iv. • arterial blood pressure, heart rate and breathing frequency monitoring is necessary 6/4/2021 Emergency medicine 68
Contraindications: hypersensitivity porphyria G-6 -P dehydrogenase deficiency 6/4/2021 Emergency medicine 69
Side effects: • hypotension (escpecially if iv. infusion was to fast) • vomiting • nausea • agranulocytosis • hypersensitivity reactions 6/4/2021 Emergency medicine 70
Methylprednisolone (Solu-Medrol ampulla 1 m. L/40 mg) Anaphylactic shock and severe acute asthma: • 1 -2 mg/kg iv. • no absolute contraindications in emergency cases • 70 kg patient: 2 mg x 70 kg x 0, 025 m. L • Result: 140 mg (3, 5 m. L) 6/4/2021 Emergency medicine 71
Side effects: • • • 6/4/2021 arterial hypertension hypokalemia headaches nausea vomiting Emergency medicine 72
Metoclopramide (Reglan ampulla 2 m. L/10 mg) Vomiting associated with gastrointestinal problems, nausea and vomiting after opioid application: • 10 mg im. or slowly iv. 6/4/2021 Emergency medicine 73
Contraindications: • gastrointestinal bleeding • mechanical intestinal obstruction or perforation • hypersensitivity • pheochromocytoma • epilepsy (precaution) 6/4/2021 Emergency medicine 74
Side effects: • • 6/4/2021 fatigue restlesness confusion headaches extrapyramidal symptoms dystonia dry mouth Emergency medicine 75
Morphine-chloride (ampulla 1 m. L/10 mg and 1 m. L/20 mg) Very strong pain (acute myocardial infarction, aortic dissection, polytrauma) and pulmonary oedema (for dyspnoea in left heart failure): • 5 -10 mg iv. slowly (10 mg diluted with 9 m. L of saline) • 10 -15 mg sc. Intramuscular injection is not recommended! 6/4/2021 Emergency medicine 76
Contraindications: • • • 6/4/2021 head injuries COPD exacerbations hypotension acute abdomen consciousness disorders Emergency medicine 77
Side effects: • • • 6/4/2021 breathing depression hypotension bradycardia consciousness disorders vomiting nausea Emergency medicine 78
N 6/4/2021 Emergency medicine 79
Naloxone (Nalone ampulla 1 m. L/0, 4 mg) Breathing depression and consciousness disorders in opioid poisoning: • 0, 4 -2 mg (1 -5 m. L) iv. in bolus or im. • can be repeated every 2 -3 minutes • maximum dose is 10 mg • hospitalisation is necessary • no absolute contraindications • side effect is apstinention syndrome 6/4/2021 Emergency medicine 80
O 6/4/2021 Emergency medicine 81
Oxytocin (Syntocinon ampulla 1 m. L/5 i. j. ) Profuse bleeding after delivery caused by UTERUS ATONY: • 5 i. j. (1 m. L) iv. slowly or 5 -10 i. j. (1 -2 m. L) im. after placental delivery • contraindication is hypersensitivity • side effects are acute transitional hypotension, arrhythmias, nausea, vomiting and allergic reactions 6/4/2021 Emergency medicine 82
P 6/4/2021 Emergency medicine 83
Promazin (Prazine ampulla 1 m. L/50 mg or 2 m. L/100 mg) Replacement for haloperidol: • 50 -100 mg im. • dose can be repeated after 5 minutes • maximum dose is 300 mg Contraindications: pregnancy, lactation, coma, hypersensitivity. . . • Side effects: dry mouth, weakness, dizziness, opstipation, extrapyramidal symptoms. . . 6/4/2021 Emergency medicine 84
Propafenone (Rytmonorm ampulla 20 m. L/70 mg) Medicamentous conversion of acute atrial fibrillation with fast ventricular response when there is NO ORGANIC HEART DISEASE: • 1 -2 mg/kg iv. • 1 mg~0, 28 m. L • 70 kg patient: 2 mg x 70 kg x 0, 28 m. L • Result: 140 mg (~40 m. L) 6/4/2021 Emergency medicine 85
Contraindications: • • 6/4/2021 severe heart insufficiency cardiogenic shock not caused by arrhythmia severe heart conduction disorders severe COPD hypotension symptomatic bradycardia heart blocks Emergency medicine 86
Side effects: • • 6/4/2021 nausea vomiting arrhyhtmias heart failure exacerbation vision problems dizziness bitter taste in mouth Emergency medicine 87
R 6/4/2021 Emergency medicine 88
Ranitidine (Ranix ampulla 2 m. L/50 mg) Anaphylactic shock in combination with Synopen: • 50 -100 mg iv. Peptic ulcer disease with hyperacidity, GERD: • 50 mg iv. in 20 m. L of saline within 5 minutes • 50 mg im. 6/4/2021 Emergency medicine 89
T 6/4/2021 Emergency medicine 90
Tramadol (ampulla 1 m. L/50 mg and 2 m. L/100 mg) Severe visceral or malignant pain: 6/4/2021 • 50 -100 mg iv. , im. or sc. Emergency medicine 91
Trospium chloride vs. Hyoscine butylbromide Trospium (Spasmex ampulla 5 m. L/0, 2 mg) Hyoscine (Buscol ampulla 1 m. L/20 mg) • colics • 0, 2 mg (5 m. L) slowly iv. • or deeply im. • colics • 20 -40 mg iv. slowly 6/4/2021 Emergency medicine 92
U 6/4/2021 Emergency medicine 93
Urapidil (Ebrantil ampulla 5 m. L/25 mg) Hypertensive crisis: • 12, 5 (2, 5 m. L)-25 mg (5 m. L)-50 mg (10 m. L) iv. bolus Contraindications are aortic and mitral stenosis. • Side effects are headache, dizziness, sweating, restlesness, palpitations, retrosternal pain and dyspnoea. 6/4/2021 Emergency medicine 94
V 6/4/2021 Emergency medicine 95
Verapamil (Isoptin ampulla 2 m. L/5 mg) Paroxysmal supraventricular tachycardia: • 5 -10 mg iv. bolus within 2 minutes • repeat dose 10 -15 mg iv. after 15 -30 minutes if necessary • maximal dose is 20 mg Contraindications are WPW, AV block second and third degree, sick sinus syndrome, congestive heart failure, hypotension, shock and ventricular tachycardia. 6/4/2021 Emergency medicine 96
Side effects: • hypotension • AV block • bradycardia • asystole 6/4/2021 Emergency medicine 97
Literature: • Jaspirica-Hrelec V. Bošan. Kilibarda I. Lijekovi u torbi liječnika hitne medicinske pomoći. • Rxlist. com • HALMED 6/4/2021 Emergency medicine 98
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