EMERGENCY PHARMACOLOGY...9/12/2013 1 EMERGENCY PHARMACOLOGY JUST SAY “KNOW” TO DRUGS Dr. Caleb...
Transcript of EMERGENCY PHARMACOLOGY...9/12/2013 1 EMERGENCY PHARMACOLOGY JUST SAY “KNOW” TO DRUGS Dr. Caleb...
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EMERGENCY PHARMACOLOGY JUST SAY “KNOW” TO DRUGS
Dr. Caleb Frankel
Emergency and Critical Care Service
September 2013
“Today’s veterinary technician is a professional, and such, has the responsibility to understand thereasons and the expected outcomes for the treatments they perform. Today’s veterinary technician ismore than a skilled set of hands. Today’s veterinary technician must know how to critically evaluate,problem solve, think, and adapt to their patient’s needs.”
WHY PHARMACOLOGY FOR NURSES?
“Today’s veterinary technician is a professional, and
such, has the responsibility to understand the reasons and the expected outcomes for the treatments they perform.
Today’s veterinary technician is more than a skilled set of hands.
Today’s veterinary technician must know how to critically evaluate, problem solve, think, and adapt to their patient’s needs.”
- Peter Bill, DVM 2010AACVM Meeting Washington DC
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WHAT YOU WILL LEARN
1. Drug Background Info
2. ER Drug Survival Guide Crash Cart & CPR Drugs
Anti-Seizure Drugs
Cardiopulmonary Drugs
Sedation and Pain Management Drugs
GI Drugs
Toxin Antidotes
3. Medication Math (made easy)
4. Drug That Don’t Play Nice
5. Reliable Resources
MEDICATIONS BACKGROUND
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History of Drugs and Medicine
FACT: 99% of drugs used today were developed in the past 60 years!
A Brief 4000 Year History of Medicine
2000 B.C.—Here, eat this root.
1000 A.D.—That root is heathen. Here, say this prayer.
1850 A.D.—That prayer is superstition. Here, drink this potion.
1920 A.D.—That potion is snake oil. Here, swallow this pill.
1945 A.D.—That pill is ineffective. Here, take this penicillin.
1955 A.D.—Oops . . . bugs mutated. Here, take this tetracycline.
1960–1999—39 more “oops.” Here, take this more powerful antibiotic.
2010 A.D.—That antibiotic is artificial! Here, eat this root.
—Anonymous
Important Definitions
Drug vs. Poison
Pharmacology vs. Pharmacokinetics
Dose vs. Dosage
Concentration
Half Life (t ½)
Generic vs. Trade (Brand) Name…
COMMON DRUG ABBREVIATIONS
- CRI = Continuous rate infusion- IV = Intravenous- IM = Intramuscular- SQ (SC) = Subcutaneous- PO = Per “os” or by mouth- PR = Per rectum
- OU = Both eyes- OD = Right eye- OS = Left eye- AU = Both ears- AD = Right ear- AS = Left ear
- PRN = as needed- cc = mL- SID = once daily (q24h / qd)- BID = twice daily- TID = three times daily (q8h)- QID = four times daily (q6h)- EOD = every other day (qod)
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Drug name: Famotidine
(Brand name: Pepcid)
Concentration (10mg/mL)
The Bottle
Drug Basics (nerd stuff)
Absorption
Distribution
Drug Clearance
Hepatic Metabolism Biliary Excretion Renal Excretion
Lipid vs. Water Soluble
First Pass Effect
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Controlled Drugs (DEA Schedules I – V)
Prescribing Legally (V-C-P-R)
Veterinarians Acting as “Pharmacies”
US’s 1994 AMDUCA (Extra-label use)
Drugs and The Law
EMERGENCY DRUG SURVIVAL GUIDE
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VETERINARY CPR IS COOL
AGAIN
CRASH CART DRUGS
Epinephrine Vasopressin Atropine
Lidocaine Amiodarone Calcium
Gluconate
Insulin
(regular)
Dextrose REVERSAL AGENTS
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CPR TREATMENT CHOICE?
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- - -
Epinephrine Vasopressin Atropine
FIRST LINE CPR DRUGS
Class: catecholamine
Uses: CPR (why?)
Action: constricts peripheral vessels (good) and speeds heart (bad)
Also for anaphylaxis and hemorrhage topically
Dose: low vs. high
Class: Hormone (ADH)
Uses: CPR (why?)
Action: Constricts peripheral vessels without heart effects
Also for Diabetes Insipidus, and VWD
Works in acidic pH?
Class: Anticholinergic
Really cool history
Uses: CPR (why?)
Action: inhibits slow down signals to heart. “vagolytic”
Also for bradycardia and for insecticide and nerve agent (OPs) toxicity
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REVERSAL AGENTS
DON’T FORGET THESE IN ANESTHETIC OR POST-ANESTHETIC ARRESTS!
Naloxone Flumazenil Atipamezole Yohimbine
OTHER CPR DRUGS
Class: antiarrhythmic
Uses: Ventricular tachycardia
Also for local anesthesia
Controversial in CPR –suppresses heart and can make defibrillation unsuccessful
Amiodarone = best for shock-resistant V-tach or v-fib? (controversial)
Lidocaine Amiodarone
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THE DYING BLOCKED CAT TRIFECTA
Calcium
Gluconate
Insulin
(regular)
Dextrose
The Problem?
What is the treatment?
Which catheter first? IVC or urinary?
How does Ca gluconate work?
How do insulin and dextrose work?
Dextrose = never give 50% peripherally or SQ
Other ER uses for these 3: Ca: Hypocalcemia, Addisonian crisis, Ca-channel
blocker overdose Insulin: Addisonian crisis, DKA/diabetes Dextrose: hypoglycemia!
THE CONTROVERSIAL CRASH CART
Doxapram
Dexamethasone (steroids)
A very important ER drug!
Indications: Anaphylaxis/allergy, asthma or life-threatening airway swelling (larpar, trach collapse), Addisonian crisis, immune disease, some cerebral edemas
Not routinely used: shock / CPR
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SEIZURE DRUGS
Diazepam Propofol Phenobarbital(Keppra)
Class: benzodiazepine
Also: sedative, anxiolytic, muscle relaxant
Works as GABA agonist
Paradoxical reactions
IV only – Quick dose
Class: anesthetic
Also: emergency intubation, anesthesia
Works via ??
RESPIRATORY ARREST (Michael Jackson). Hypotension
IV only
Class: Barbiturate
Also: sialadenosis
Works centrally to inhibit various chemicals - depressant
Very sedating for first 1-2 weeks after starting. Hepatotoxic.
IV only – very irritating otherwise
Mannitol
CARDIO / RESPIRATORY DRUGS
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MY. WORST. NIGHTMARE.
FELINE ASTHMA TOOLBOX
Terbutaline Dexamethasone SP
Albuterol
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CONGESTIVE HEART FAILURE (simple)
Furosemide (Lasix) Nitroprusside
Reduce resistance pumping into (vasodilator)
Reduces amount of fluid to pump (diuretic)
ER PAIN KILLERS
Butorphanol Buprenorphine
Hydromorphone
Morphine
Methadone
FentanylButorphanol
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MY FAVORITE ER PAIN KILLERS
The “Ideal” Pain Killer
Works fast Powerful Minimal sedation No side effects Reversible Not controlled
SOME HIGHLIGHTS REVERSIBLE! (how?)
Hydromorphone – cheap, fast, reversible. (Sedating, Panting +/- Vomiting)
Methadone – hydro plus NMDA blocker without side effects! (Expensive)
Fentanyl – short acting, potent (need CRI, respiratory depression). Patches?
DEA Schedule 2 Drugs
ER SEDATIONAcepromazine Butorphanol Propofol
ER Uses: laryngeal paralysis, tracheal collapse, respiratory distress, heat stroke
Also: antihistamine, antiemetic, hypothermic
Drops blood pressure and takes full 30-60 minutes until onset!
ER Uses: Respiratory emergencies, mild-moderate sedation for diagnostics, anti-anxiety
Generally safe with minimal side effects
Mild pain reliever but only for 30 minutes!
ER Uses: emergency intubation, short anesthesia, seizures
Never forget respiratory arrest (I intubate most animals on propofol)
Dexmedetomidine
ER Uses: short ER procedures, pain control!
Only for otherwise healthy animals
Causes very low heart rates! (How to treat?)
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COMMON GI MEDICATIONS
(Pepcid) (Protonix)
Sucralfate (Carafate)
(Prilosec)
Pepcid / Tagamet / Zantac Block histamine receptor on the stomach
acid producing pump Pepcid = most effective in pets and least
side effects Zantac sometimes used in constipated cats
Protonix / Prilosec / Nexium Blocks proton pump Takes some time to work
Stomach ulcer coater
COMMON GI MEDICATIONS
(Zofran) (Reglan)Maropitant
Metronidazole (Flagyl)
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TOXICITY TIME
DECONTAMINATION (VOMITING)Hydrogen Peroxide Apomorphine Xylazine
How does is work? Local irritant to mucosa
Dose: 1-5 mL/kg (Max Dog = 50mL, Max Cat = 10 mL)
Not my favorite (I try to avoid in this day and age)
The emetic of choice in dogs (why?)
Generally safe with minimal side effects
Comes in eye drop or injectable solution (most effective).
Emetic of choice in cats (why?)
Very sedating
Not reliable but the best we know.
Reversible? Yohimbine
When NOT to induce vomiting?
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ACTIVATED CHACOAL
What is it?
Must come in contact with toxin to work
Which toxins? “-ol” rule
Many formulations
Risks?
ANIMAL POISON RX
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MEDICATION MATH (MADE EASY)
Pharmacology Math Toolbox
MATH PROBLEM SOLUTION NOTES
POUNDS VS. KILOGRAMS 2.2 Pounds = 1 kilogram (kg) Every 22 pounds = 10kg
DRUG PERCENTAGES 1% = 10mg/mLJust move the decimal 1 place to right
LIQUID DRUG DOSESMG drug = WEIGHT KG x dose (mg/kg)ML drug = MG ÷ mg/mL on bottle
Exa: dr asks for 6mg/kg and 10kg dog. Drug is 15mg/mLAnswer = 4mL
IVF ADDITIVESDosed in mg/L, mEq/L or %Solve for mL
If not exactly 1 liter left, set up a ratio and cross multiply
FLUID PUMP BOLUSESGiven: mL desired over certain time
𝑹𝒂𝒕𝒆 = 𝒎𝑳 𝒙 (𝟔𝟎
𝒕𝒊𝒎𝒆 𝒊𝒏 𝒎𝒊𝒏𝒔)
Set VTBI as mL given by doctorSet Rate as what you calculated
CRI CALCULATIONS
𝑲𝑮 ∗ 𝑫 ∗ 𝑭
𝑰𝑽𝑭 𝒓𝒂𝒕𝒆= 𝑴𝒈
D = Dose in ug/kg/minF = Fluid factor (0.06 x every 1 mL fluid) IVF rate = ml/hr
Mg = mg to add to bag of fluids
Lots of ways to calculate CRIs–ultimately need to know dose and fluid rate to start and need to come up with mg to add to fluid.
For CRI doses, know that :1mg/kg/hr = 16.7ug/kg/min
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QUICK DOSING SECRETS
Valium, Lidocaine, Naloxone, Flumazenil
Dextrose in IVF Bags
Calcium Gluconate
Shock IVF Boluses
COMMON DRUG
REACTIONS
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INTERACTIONS TO KNOW
DRUG(S) INFORMATION
SucralfateBinds drugs decreasing absorption (esp
Fluroquinolones antibiotics – Baytril). Timing!
Tramadol + Mirtazipine Serotonin syndrome!
Phenobarbital
Increases liver metabolism of some drugs. Thus,
decreases the action of many drugs (theophylline,
lidocaine, valium, tramadol). Only seen in dogs.
Omeprazole &
Cimetidine
Decreases liver metabolism of some drugs. Thus
increases toxicity of tramadol, diazepam,
lidocaine, theophylline. Clopidogrel (Plavix) can’t e
activated (won’t work).
Substitute for pantoprazole and Pepcid.
FDA’s veterinary drug reaction hotline: 1-888-FDA-VETS
INTERACTIONS TO KNOW
DRUG(S) INFORMATION
Furosemide + DigoxinBoth are used for heart failure but furosemide
causes increased digoxin levels.
Furosemide +
Lidocaine
Lidocaine doesn’t work well if there is
hypokalemia (low K) and furosemide lowers K.
These also don’t mix well with others in IV line.
Reglan + DopamineReglan is a dopamine blocker. Kidney effects from
dopamine are not affected.
Fluroquinolones +
TheophyllineIncreases theophylline to possibly toxic levels.
Butorphanol Antagonizes other opiate pain killers.
More resources (IVF interactions, etc) online…
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RELIABLE DRUG RESOURCES
Drug Package Inserts
Plumb’s VDH (7th)
Trissel Handbook on Injectable Drugs
Other Textbooks
Apps / Calculators / Online Resources:
www.vmdtechnology.com
QUESTIONS?
LECTURE GOODIES: www.vmdtechnology.com/er-pharma-9122013 | Password = VSEC