Pharm E4- ER

What is the rapid sequential process of emergent tracheal intubation?

Preparation → sedation → paralysis

What physiologic response can we expect to occur from laryngoscopy?

Inc/dec HR, inc ICP, inc BP, inc airway resistance (bronchospasm)

What 2 meds are used for pretreatment before intubation?

Lidocaine & atropine

Which drug?

• antidysrhythmic with anesthetic properties

• given 1-2 minutes before intubation

• blunts cough//gag reflex

• used to prevent rise in ICP

  • good for suspicion of inc ICP, TBI, cerebral swelling

Lidocaine

Which drug?

• antimuscarinic given prior to intubation

• prevents worsening bradycardia

• also used if difficult to visualize vocal cords d/t increased secretions → helps dry

Atropine

What is the best pretreatment to give prior to intubation in a small child getting repeated doses of succinylcholine (prone to bradycardia)?

Atropine

Is a short acting sedative or long acting sedative preferred for intubation?

Short acting → need to be able to correct if things go wrong or perform neuro exam after

Which drug?

• sedative/hypnotic for general anesthesia induction & prior to NMB; produces light sleep to deep coma

  • imidazole derivative unrelated to other agents

  • EEG changes similar to barbiturates

• rapid onset & offset

• minimal hemodynamic & respiratory effects

Etomidate

What is the MOA of etomidate?

Activate GABA-A receptors to enhance GABA → hyper polarizes neurons w/ Cl → keeps APs from occurring

What are CIs to etomidate?

Known hypersensitivity

What is the DOA of etomidate?

5-10 minutes

*rapid onset LOC & offset

What drug interactions are seen with etomidate?

Increased effect of sedatives, hypnotics, & opiates

No interaction w/ any NMB

The following SEs are seen with which drug?

• Trismus

  • muscles lock up, more difficult for paralytic to kick in & to intubate

• Muscle twitching → myoclonic jerks

• pain at injection site

• dec plasma cortisol

  • lasts ~8 hrs after injection

  • caution with septic patients

Etomidate

What may need to be given with etomidate if used in a septic patient d/t decreased cortisol?

Additional steroids (hydrocortisone), maybe vasopressors

What BZDs are used as induction agents before intubation & provide sedation, amnesia, & anticonvulsant properties but no analgesia?

*used as adjuncts, not deep enough sedation alone

Midazolam (faster onset 1-2 min, 20 min DOA) & Lorazepam (longer DOA)

What would be a good adjunct induction agent prior to intubation if a patient is having seizures?

BZDs (lorazepam)

When is a decreased dose of midazolam needed d/t a longer half life?

Obesity, geriatric, CHF, hepatic or renal insufficiency

Which drug?

• dissociative anesthetic derived from PCP

• ultrashort & rapid acting → onset: 30-40s; DOA: 5-10 min

• bronchodilator & leaves resp drive intact

• better for hypotensive & status asthmaticus patients

Ketamine

In what patients should ketamine be avoided?

HTN and cerebral swelling/TBI d/t catecholamine release that increases HR, BP, & ICP

What SEs are seen with ketamine?

Sialogogue (inc saliva, pretx w/ atropine), elevated ICP, dysphoric reactions, vomiting (pretx w/ zofran)

What pretreatment can be given before ketamine to prevent sialogogue?

Atropine

What pretreatment should be given before ketamine to prevent vomiting, which would increase the risk of aspiration when intubating?

Zofran

What induction agent is better for intubation in a patient with hypotension or for status asthmaticus?

Ketamine

Which induction agent?

• ultrashort & rapid acting → onset: 10-50 s, DOA: 3-10 min

• can cause hypotension & decreased CNS perfusion

• avoid in egg & soy allergy

Propofol

Which sedative increases BP?

Ketamine

Which sedative decreases BP?

Propofol

Which sedative does not affect BP?

Etomidate

What class of drugs?

• block natural transmission of nerve impulses to skeletal muscles

• No effect on LOC, pain perception, seizure activity

• No direct effect on: heart, digestive system, brain, pupillary response, smooth muscle, other organ systems

Neuromuscular blockers

What drugs are depolarizing NMBs?

Succinylcholine

What drugs are non-depolarizing NMBs?

Pancuronium, Cisatracurium, Rocuronium, Vecuronium

What is the MOA of succinylcholine?

(2 phases) Initial depolarization - activates receptor→ fasciculations (short lived) → stays on receptor, prevents from resetting/remains refractory→ continuous stimulation desensitizes receptors & close → flaccid paralysis

What paralytic agent?

• rapid & short→ onset: 30-90s, DOA; 5-10 min

  • given 30-60s after sedative

• plasma esterase metabolism

  • *def in enzyme → longer DOA

• renal excretion

• no reversal agent

Succinylcholine

What are CIs to succinylcholine?

2-5 days after injuries/ conditions regulating ACh receptors

Narrow angle glaucoma (inc IOP)

PHx or FHx of malignant hyperthermia

Pseudocholinesterase def, neuromuscular dz, hyperkalemia

What SEs are seen with succinylcholine?

Fasiculations, hyperkalemia, prolonged neuromuscular blockade (esterase def), bradycardia (give atropine), & malignant hyperthermia

What should be given with succinylcholine to prevent fasciculations if you suspect a patient has increased ICP (further increases ICP)?

Lidocaine (& defasciculating dose of rocuronium)

What conditions can cause ACh receptor up regulation (leading to hyperkalemia, which is worsened by succinylcholine)?

*avoid ≥2-5 days after condition

Burns (esp 5 days after), denervation or neuromuscular disorders, crush injuries, intra-abdominal infx, myopathies, rhabdomyolysis, renal failure

Which of the following patients is NOT CI to succinylcholine? (**Test Q)

• Pt w/ pre-existing hyperkalemia

• Pt w/ severe burns after house fire 4 days ago

• Pt w/ longstanding muscular dystrophy

• Pt w/ massive crush injury from 20 minutes ago

Pt w/ massive crush injury from 20 minutes ago

What is the treatment for malignant hyperthermia?

Dantrolene, temp reduction (ice packs in groin/axilla, evaporative cooling, cold IVFs), & bicarb for lactic acidosis

What can be given to prevent bradycardia w/ succinylcholine?

Atropine

What paralytic agents?

• Onset 2-3 min, DOA 20-30 min

  • longer; difficult if neuro exam is needed

• safer, not many CIs, may be used in CV, pulm, & neuro emergencies

• hepatic & renal metabolism (failure → longer DOA)

• does not cause hypotension or tachycardia (neutral)

Vecuronium

What patients need less vecuronium to maintain paralysis?

Renal or hepatic failure

Which paralytic agent?

• less vagolytic properties

• fastest onset of non-depolarizing NMBs → 30-60s, DOA 20-75 minutes

Rocuronium

What drug is an acetylcholinesterase inhibitor that is a competitive antagonist for non-depolarizing NMBs & is the reversal agent for rocuronium & vecuronium?

Neostigmine

What should be done if giving an NMB and you are concerned about seizures?

Give anticonvulsants first & have a bedside EEG

Do NMBs treat seizure activity?

NO - stops the outward signs of a seizure but it is still occurring internally

What drug?

• long acting non-depolarizing NMB

• vagolytic → tachycardia

  • not good for CV patients

Pancuronium

What drug?

• Intermediate acting non-depolarizing NMB

• no hepatic/ renal metabolism/ elimination → good for organ impaired patients

• no issues w/ CV effects

Cisatracurium

What agents would be used in the following situations?

• ventilatory synchronization

• increased ICP → need them to not move in order to reduce ICP

• prevent shivering during therapeutic hypothermia

• facilitating diagnostic or therapeutic procedures

Long acting NMBs

What complications are associated with long term paralytics / NMBs?

VTE (tx w/ SCDs, heparin, etc)

VAP (prevent w/ oral hygiene, chlorhexidine)

Gastric ulcers (give H2RA or PPI)

Corneal abrasions (not blinking → tape eyes, use ointments)

ICU neuropathy

What is used for paralytic monitoring?

PN stimulator / train of 4 (MC ulnar n.) → goal is 1-2 twitches

Which agent should be longer lasting, a paralytic or a sedative?

*keep track of timing; consider 2nd doses at 5-10 minutes

Sedative

What is a common sedative + paralytic combo given for intubation?

Succinylcholine (4-10 min) & Etomidate (6-10 min)

*consider 2nd dose at 5-10 min

Patient is coming in with suspected head trauma and you are worried about increased ICP. Patient is also hypotensive. What are the best agents to use and what is the correct order?

***Test Q example

Lidocaine → Etomidate → Rocaronium

What agents are used in ACLS and are typically all found in crash carts?

Adenosine, amiodarone, atropine, calcium, dextrose, epi, lidocaine, magnesium, naloxone, sodium bicarbonate

What is the MOA of epinephrine?

Endogenous catecholamine: alpha & beta stimulation → increases HR, BP, & coronary perfusion

What are ACLS indications for epinephrine?

Symptomatic bradycardia → HR < 60 & evidence of poor perfusion

Cardiac arrest → VF, VT, PEA, asystole

What is the max IV/IO epi dose?

1 mg/dose

What is the max ET epi dose?

2.5 mg/dose

What dosage routes are used when IV can’t be established?

IO > ET

Why do ET medication routes forms require higher doses?

Different bioavailability in the lungs → less absorption

Which is a higher dose of Epi; 1:1,000 or 1:10,000?

1:1,000 (1 mg in 1 mL)

What medications are available in ET dosing (although rarely used)?

Lidocaine

Epinephrine

Atropine

Naloxone

What ACLS agent?

• Muscarinic receptor antagonist → blocks Ach receptors on heart

• Vagloytic: dec actions of vagus nerve → inc AV conduction & HR

• Indications

  • symptomatic bradycardia (AV block or vagal mediated)

  • increased secretions

  • *not used in cardiac arrest anymore

Atropine

What is the max IV dose of atropine?

0.5 mg

What ACLS agents are used for bradycardia?

Epinephrine & atropine

What drug is an adenosine receptor agonist that causes AV node conduction block & interrupts reentry circuits (stops & restarts heart)?

Adenosine

What are indications for adenosine?

PSVT / supraventricular tachycardia

What happens if adenosine is administered too slowly?

Degrades before it reaches the heart d/t very short half life (< 10s); ineffective

How should adenosine be administered?

2 syringes w/ T-connector or stopcock; flush w/ ≥5 mL immediately after (IDK what we’re flushing with but just do it)

What drug?

• Class III anti arrhythmic → blocks K channel efflux (+ na, ca, etc)

• Rhythm control; slows ventricular conduction

• IV push in cardiac arrest

• Given over 20-60 min w/ perfusing rhythm

  • bolus/ loading dose upfront, then continuous infusion if effective

Amiodarone

What should you watch for when administering amiodarone?

Hypotension & bradycardia (not worried when actively coding)

What are indications for amiodarone?

SVT unresponsive to adenosine, wide complex tachycardias, Vfib, tachycardia

What is the max single dose of amiodarone?

300 mg

Which ACLS drug?

• class IB anti arrhythmic → blocks myocardial Na channels & suppresses ventricular arrhythmias

  • works more on dead/ dying tissue → shortens refractory period + conducts electricity

• risk of increased toxicity in renal & hepatic impairment d/t dec clearance

Lidocaine

What should be done to the dose of lidocaine if using in hepatic impairment or CHF?

Use ½ dose

What are ACLS indications for lidocaine?

Vfib / tachycardia (if amiodarone not available)

What is the drug of choice for torsades de pointes?

Magnesium

What ADRs are seen with magnesium?

Flushing d/t vasodilator, hypotension if given too quickly (*give NS at same time)

What adverse reactions are seen with sodium bicarbonate?

Tetany (transient hypocalcemia)

Why might you see hypocalcemia in a patient who was given PRBCs after a massive trauma?

Citrate based anticoagulant was also given to prevent clots

Which form of calcium?

• smaller molecule, contains more Ca, more potent

• rough on veins → phlebitis

  • given in unconscious or coding patient

  • use deepest vein possible, central line preferred

Calcium Chloride

Which form of calcium?

• bigger molecule, less room for ca, less potent

• easier on veins but requires bigger dose

Calcium gluconate

What is the dosing ratio of calcium gluconate vs chloride?

3 : 1

What ADRs can be seen with calcium?

Thrombophlebitis, tissue necrosis

Why should caution be used when giving naloxone while a patient is intubated?

Reverses CNS depression, pt will wake up & start to fight tube

Monitor CO2 response; opioids turns of CO2 response; RR may look fine but CO2 is high → give narcan

What drug?

• Indication: hypoglycemia

• ADR: irritating to veins

  • use smaller concentration on kids/ conscious pts

    • 10% < 2 y/o

    • 25% > 2 y/o

  • use higher concentrations if coding / unconscious

    • 50% - adults

Dextrose

Besides dextrose, what else can be used to treat hypoglycemia?

PO glucose if possible or glucagon if unconscious

IDK if he’ll ask about the calories in nutrients but he mentioned it so here they are

Carbs: 4 cal/g

Protein: 4 cal/g

Fat: 9 cal/g (energy dense)

Alcohol: 7 cal/g

What is the treatment for a shockable rhythm (Vfib or Vtach)?

CPR & shock → epi → amiodarone (MC) or lido

What is the treatment for a non shockable rhythm (systole, PEA)?

Epi q 3-5 min & CPR

adult cardiac arrest algorithm

What is the treatment for adult tachy w/ a pulse (PSVT)?

Vagal maneuvers → adenosine → BBs (labetolol) or non DHP CCBs (deltiazam, verapamil)

Adult tachy w/ a pulse treatment algorithm

What is the treatment for adult bradycardia?

Atropine → DA infusion or EPI infusion (postive chronotrops, rate control)

Adult bradycardia algorithm

Which weight should you go with if a pediatric patient is between weights and is coding?

Round up

What are agents that increases speed of heart contractions (inc HR)?

Chronotropes

What are agents that increase contractility of heart (used if bad pump/HF)?

Inotropes

What are agents that increase peripheral vascular resistance (inc BP)?

Vasopressors

What drug is a metabolic precursor to epi & NE (converted peripherally to adrenergic agents on heart) that acts similarly to endogenous dopamine?

Dopamine (Intropin)