Emergency Drugs 411MDS Dr Hesham Khalil Collapse of a patient in the dental surgery is an infrequent occurrence whose incidence is largely

unknown. Dentists must be aware of the potential medical complications that may arise through the delivery of dental care to compromised patients. in one study, all final-year dental students and recent dental graduates failed a practical test assessing their ability to perform cardiopulmonary resuscitation. During the last decade, many dentists have expressed concern about the management of medical emergencies and requested the introduction of an official emergency kit into surgeries. In all cases of emergencies, the best method of managing medical emergencies is by preventing them from occurring in the first place. With this in mind, it is essential to take a comprehensive medical history from any patient about to receive dental care. The following section reviews the more common emergency drugs that the dental team may have to administer in general dental practice. 2 OXYGEN Indications Oxygen is indicated in all medical emergencies except hyperventilation. Oxygenation prevents hypoxia that may be damaging to vital organs such as the brain and heart. Administration Ensuring Airway Patency Before oxygen can be delivered, it is essential to ensure that the airway is patent.

Foreign bodies, blood, vomit, and soft tissues may occlude the air space. The airway may be reestablished by using the head tilt and chin lift or jaw thrust techniques. Airway adjuncts such as oropharyngeal (Guedel) airways may be used in the unconscious patient to hold the tongue in an anterior position away from the posterior pharyngeal wall. These airways are contraindicated in conscious or semiconscious patients where protective reflexes are active. Oxygenation If the patient is breathing spontaneously, a facemask with an attached oxygen supply, running at a flow rate between 4 and 6 l/min, may be used to deliver oxygen and help prevent hypoxia. Positive pressure ventilatory support may be provided in respiratory arrest. Dose During cardiorespiratory arrest, the chest compression to ventilation ratio for adults 15:2 if one resuscitator is present and 5:1 if two are present. Adrenaline Indications Adrenaline may be administered in the following situations: anaphylactic shock; 3 cardiac arrest. Anaphylactic Shock An allergic (type 1 hypersensitivity) reaction may be precipitated by any material or drug to which the patient has been sensitized. Life-threatening events include cardiovascular collapse (90%), bronchospasm (30%), angio-oedema (25%), and pulmonary oedema (49%).Severity varies, and onset of anaphylaxis may be delayed for up to 6 hours or be biphasic, reoccurring in 5% of patients after clinical recovery.

In addition to adrenaline, high flow oxygen should be administered to all patients in anaphylactic shock. Second-line drugs, used to prevent relapse, are chlorpheniramine and hydrocortisone. Cardiac Arrest Adrenaline is used hi advanced cardiac life support protocols. Mode of Action Adrenaline is a sympathomimetic amine that activates both alpha and Beta adrenoccptors.. Contraction of vascular smooth muscle (alpha-mediated). An increased blood pressure helps maintain cerebral and coronary perfusion. Increased force and rate of cardiac contraction (Beta1-mediated). This action increases cardiac output, which helps to maintain the blood pressure. However, this may be damaging as it increases myocardial oxygen requirements and may precipitate ischemia. Relaxation of bronchial smooth muscle (Beta2-mediated). Increasing the caliber of the airway in acute anaphylaxis helps to re-establish airflow restricted by bronchospasm and oedema. Inhibition of histamine release by mast cells (Beta2-effecf). Histamine is an important early mediator, responsible for some of the haemodynamic changes encountered in anaphylactic reactions. Administration Adrenaline may be given intramuscularly, subcutaneously or intravenously. 4 Dose Adrenaline is obtainable in two concentrations: 1:1000 (reserved for intramuscular and subcutaneous use) and 1:10 000 (for intravenous administration). It is available in

ampoules or prefilled. The following Table outlines the recommended volume of 1:1000 adrenaline that should be administered according to age during anaphylactic reactions. GLYCERYL TRINITRATE Indications Glyceryl trinitrate (GTN) is used for the prophylaxis and relief of angina. Angina, defined as discomfort due to myocardial ischaemia, occurs whenever there is an imbalance between myocardial oxygen supply and demand. Atherosclerotic narrowing of the coronary lumen results in insufficient oxygenated blood being delivered to the myocardium during periods of increased activity. Mode of Action The principle site of action of GTN is smooth muscle. Within the smooth muscle cell, GTN is converted to nitric oxide which activates the enzyme soluble guanylate cyclase (SGC). Activation of SGC results in increased cyclic-guanosine monophosphate (cGMP) production, which leads to relaxation of the-smooth muscle cell.. GTN improves the myocardial oxygen supply : demand ratio by: 5 reducing cardiac workload increasing the blood supply to the myocardium Adverse effects of GTN include headaches, postural hypotension, and flushing. Administration 1. Tablets (300 micrograms). Uptake is delayed because of the initial time taken for the tablet to dissolve. 2. Spray (400 micrograms metered dose). This is preferable to tablets as the solution is rapidly absorbed, no special storage is required, and die spray has a shelf life of

Dose If a patient known to suffer from angina experiences chest pain, they should be placed upright to facilitate respiratory movements. In adults, a dose of 0.3 to 1 mg should produce symptomatic relief within 3 minutes. The effective duration of action is only 20 or 30 minutes; thus, dosing may have to be repeated. Oxygen should also be administered to all patients experiencing acute chest pain. If symptoms are not relieved within 10 minutes, myocardial infarction should be suspected. MTROUS OXIDE Indications Nitrous oxide may be used for its analgesic properties in the initial management of myocardial infarction (MI). The pain experienced during an MI is often more severe and of longer duration than that in angina. It may lead to further deterioration of cardiac function as it increases sympathetic output, 6 which will elevate the oxygen demands of an already starved myocardium. Mode of Action Many theories of the mechanism of action of general anaesthetic agents such as nitrous oxide have been proposed. It is thought that these agents alter, either directly or indirectly, the function of the membrane proteins involved in the conduction of nervous impulses. Theories that may be applicable include the following. 1. The protein theory 2. The lipid theory. 3. The water theory.. Administration and Dose A combination of 50% nitrous oxide and 50% oxygen is used to produce analgesia

without loss of consciousness. GLUCAGON Glucagon is a pancreatic hormone that stimulates hepatic glycogenolysis and gluconeogenesis. Indications Glucagon may be given to the unconscious hypoglycaemic patient when intravenous access cannot be secured for the administration of glucose. In conscious patients, a sweet drink is sufficient to elevate plasma glucose levels. Oral glucose must not be given to unconscious patients because of the risk of pulmonary aspiration. Hypoglycaemia, defined as a blood glucose concentration of less than 2.5 mmol/l, most commonly occurs in insulin-dependent diabetes. Hypoglycaemia may result if7 a patient takes an insulin overdose; the patient takes the correct dose but with no food; or the patient exercises or undergoes a stressful situation. Mode of Action Glucagon increases plasma glucose by stimulating glycogenolysis and gluconeogenesis in the liver. An additional action is inhibition of glycogen synthesis and glucose oxidation. In adipose and hepatic tissues, glucagon causes lipolysis, resulting in the production of fatty acids which further increase gluconeogenesis. Administration and Dose In adults, 1 mg (0.5 mg in children up to 12 years) may be given intramuscularly into the deltoid or gluteal areas. GLUCOSE Indications

Glucose may be administered to the conscious or unconscious hypoglycemic patient. Administration Glucose may be given orally, intravenously or transmucosally. Intravenous administration is the most rapid and effective method of elevating plasma glucose levels. SALBUTAMOL Indications Salbutamol, a potent bronchodilator, is used in the management of acute asthma. 8 Mode of Action Salbutamol is a selective Beta2-agonist which relaxes bronchial smooth muscle. Administration To minimize the chance of adverse effects and to produce the most rapid onset of action, salbutamol is administered by inhalation (nebulizer) HYDROCORTISONE Hydrocortisone, an endogenous adrenal hormone, possesses predominantly glucocorticoid activity and is essential for human survival Administration of steroids for therapeutic purposes has a negative feedback effect on the hypothalamus and anterior pituitary gland, which eventually leads to atrophy of the adrenal cortex and resultant inability to secrete hydrocortisone in response to stress (acute adrenal insufficiency). Under these circumstances, a patient may collapse due to hypoglycaemia and hypotension if a stressful situation, such as dental treatment, is encountered. Therefore, exogenous hydrocortisone should be administered pre-operatively to susceptible patients to restore the normal physiological response to stress.

If acute adrenal insufficiency does occur, prompt administration of steroids and immediate hospitalization is recommended. Administration and Dose Hydrocortisone may be administered by the oral, intramuscular or intravenous routes. The dose varies according to the age and situation (25 to 200 mg). DIAZEPAM9 Indications Diazepam is indicated in patients suffering from status epilepticus. Status epilepticus is the term applied to prolonged seizures or multiple seizures occurring without recovery of consciousness between them. The patient is at risk of brain damage due to cerebral hypoxia and inhalation of vomit or saliva. It is a life-threatening disorder, demanding urgent emergency treatment and hospitalization. Mode of Action Epilepsy is a disorder in which there are recurrent episodes of altered cerebral function associated with outbursts of excessive discharge of cerebral neurones. It is likely that both a reduction in inhibitory neuronal discharge and excessive excitation play a part in the genesis of seizures. The anticonvulsant mechanism of the benzodiazepines is thought to result from the augmentation of the pharmacological effects of the inhibitory neurotransmitter gammaaminobutyric acid (GABA) acting at GABAA receptors within the central nervous system. The benzodiazepine is thought to bind to the GABAA receptor and induce conformational changes that increase the affinity of the receptor for GABA. This results in an increased, number of inhibitory chlorine channels being opened for any given concentration of neurotransmitter. Administration and Dose Diazepam may be administered by the intravenous route or per rectum. In adults, 10

mg may be given intravenously over 2 minutes. The recommended intravenous dose for children is 200 to 300 microgram/kg. If intravenous access cannot be achieved, diazepam solution is available and is absorbed rapidly when administered by the rectal route. Intramuscular midazolam has anticonvulsant activity comparable to that of intravenously administered diazepam.10 FLUMAZENIL Flumazenil, an imidazo-benzodiazepine, was the first specific benzodiazepine antagonist to undergo extensive clinical trials. Indications Flumazenil is used for the reversal of accidental oversedation in patients sensitive to benzodiazepines, and reversal of benzodiazepine-induced respiratory depression. Mode of Action Flumazenil is a competitive benzodiazepine antagonist. It binds with high affinity to the same site as benzodiazepine agonists and thus prevents the enhancement of the effects of GAB A induced by these agents. Potential adverse effects may include nausea, vomiting, sweating and shivering. Flumazenil may also lower the seizure threshold and should be used with caution in epileptic patients or any patient on long-term benzodiazepine therapy. Administration and Dose Flumazenil is administered by the intravenous route. The adult dose should be titrated according to the individual patient's response: initially, 200 micrograms over 15 seconds, then 100 |micrograms at 60-second intervals to a maximum

of 1 mg, if required. There is insufficient data at present to make dosage recommendations for children. It should therefore be administered only if the potential benefits outweigh the risks. CHLORPHENIRAMINE Indications Chlorpheniramine is used for second-line management of anaphylaxis and treatment of allergic reactions localized to the skin. Mode of Action11 Chlorpheniramine competitively antagonizes the effects of histamine, which is released by mast cells and basophils, on histamine-1 receptors. It helps to reverse the following histamine-induced effects: increases in vascular permeability; bronchial smooth muscle contraction; and bronchospasm. Administration and Dose The drug may be given orally, intramuscularly, subcutaneously or intravenously. For the management of allergic reactions localized to the skin, a dose of 4 mg in adults may be administered orally every 4 to 6 h, to a maximum of 24 mg/day.

The 10 Most Common Emergency Drugs.

1.

Epinephrine - increases heart rate, constricts blood vessels, dilates Lidocaine - local anesthetic and antiarrhythmic drug. Furosemide - loop diuretic used in the treatment of congestive

air passages. 2. 3.

heart failure and edema.

4.

Digoxin - cardiac glycoside widely used in the treatent of various

heart conditions like atrial fibrillation, atrial flutter, and sometimes heart failure that cannot be controlled by other medications. 5. 6. 7. 8. 9. 10. Sodium Bicarbonate - used as a buffer in respiratory acidosisDopamine Hydrochloride - increases heart rate and blood Nitroglycerin - vasodilator to treat heart conditions, such as Atrophine Sulfate - used to treat episodes of bradycardia, Dobutamine Hydrochloride - used in treatment of heart failure Morphine Sulfate - used to treat both acute and chronic pain. Also induced cardiac arrests. pressure. angina and chronic heart failure. asystole and cardiac arrest. and cardiogenic shock. used for pain due to myocardial infarction and labor.
Dopastat, Intropin, Revimine Action: Naturally occurring neurotransmitter and immediate precursor of norepinephrine. Major cardiovascular effects produced by direct action on alpha- and beta-adrenergic receptors and on specific dopaminergic receptors in mesenteric and renal vascular beds. Classifications: AUTONOMIC NERVOUS SYSTEM AGENT; ALPHA- AND BETA-ADRENERGIC AGONIST (SYMPATHOMIMETIC) Indication: To correct hemodynamic imbalance in shock syndrome due to MI (cardiogenic shock), trauma, endotoxic septicemia (septic shock), open heart surgery, and CHF.

Dopamine Hydrochloride - Injection 40 mg/mL - Injection 80mg/mL - Injection 160 mg/mL Dopamine Hydrochloride in Dextrose 5% - Injection 200 mg per 250 mL (0.8 mg/mL) - Injection 400 mg per 500 mL (0.8 mg/mL) - Injection 400 mg per 250 mL (1.6 mg/mL) - Injection 800 mg per 500 mL (1.6 mg/mL) - Injection 800 mg per 250 mL (3.2 mg/mL)

Pharmacology
Stimulates beta-1 receptors in the heart, causing more complete and forceful contractions (inotropy). Also acts on alpha receptors (dose dependent) and has dopaminergic effects.

Pharmacokinetics
Distribution
Widely distributed; does not cross the blood-brain barrier to a significant extent.

Metabolism
Metabolized in the liver, kidney, and plasma by MAO and catechol-O-methyltransferase to inactive compounds. Approximately 25% of dose is taken up in the adrenergic nerve terminals where it is hydrolyzed to norepinephrine.

Elimination
Half-life approximately 2 min. Approximately 80% excreted in the urine within 24 h as metabolites; a very small amount excreted unchanged.

Onset
Within 5 min.

Duration
Less than 10 min.

Indications and Usage

Correction of hemodynamic imbalances present in shock syndrome after MI, trauma, endotoxic septicemia, open heart surgery, and renal failure or chronic cardiac decompensation (eg, CHF).

Unlabeled Uses
Calcium channel blocker or beta-blocker overdose; drug-induced hypovolemic shock; treatment of RDS in infants; COPD; CHF.

Contraindications
Pheochromocytoma; uncorrected tachyarrhythmias; ventricular fibrillation; allergy to corn/corn products (dextrose solutions).

Dosage and Administration

Adults and Children IV Initial dose of 2 to 5mcg/kg/min with incremental changes of 5 to 10 mcg/kg/min gradually until adequate response is noted. Most patients are maintained at less than 20 mcg/kg/min. If dosage exceeds 50mcg/kg/min, assess renal function frequently.

General Advice

Administer by IV infusion only, preferably into a large vein. Metering device is essential for controlling rate of flow. Administration into an umbilical artery catheter is not recommended. Dopamine is potent drug. Dilute before use if not prediluted.

Do not use if solution is discolored. Chemically incompatible with alkaline solutions, including sodium bicarbonate or other alkaline IV solutions (dopamine is inactivated). Do not mix dopamine in the same container with alteplase because particulate matter has been observed. Do not add dopamine to amphotericin B solutions because amphotericin B is physically unstable in dopaminecontaining solutions. When appropriate, increase blood volume with whole blood or plasma. If a marked decrease in pulse pressure and disproportionate increase in diastolic BP are observed, the rate of infusion should be decreased and the patient monitored for further evidence of predominant vasoconstrictive activity, unless such an effect is desired. If an increased number of ectopic beats are observed, the dose should be reduced if possible. Chemically incompatible with alkaline solutions (drug is inactivated). Avoid contact with oxidizing agents or iron salts.

Storage/Stability
Store at 68 to 77F. Avoid excessive heat. Protect from freezing. Dilute just prior to administration. Solution is stable for 24 h after dilution.

Nifedipine is a dihydropyridine calcium channel blocker and is used mainly as an antianginal and antihypertensive. Most recent studies showed that Nifedipine can be used in Raynauds phenomenon, premature labor, and painful spasms of the esophagus and tetanus patients. Common brand names for Nifedipine are Adalat, Calcibloc, Darat, Hartigard, Heblopin, Hyperten, Nelapine, Nifestad, and Odipin. Nifedipine is classified as a Calcium channel blocker, Antianginal, and Antihypertensive.

Indication for Nifedipine

Nifedipine is used in the treatment of angina due to coronary artery spasm (Prinzmetals variant angina), chronic stable angina (Effortassociated angina). It is also used in the treatment of essential hypertension. Nifedipine can also be used in the treatment of Raynauds phenomena.

Routes and Dosage of Nifedipine

Alert: May give 10-20mg sublingual as needed for acute attacks of angina. Prinzmetals Variant Angina, Chronic Stable Angina PO: ADULTS, ELDERLY: Initially, 10mg three times a day. Increase at 7 to 14 day intervals. MAINTENANCE: 10mg three times a day up to 30mg four times a day. Extended-release: ADULTS, ELDERLY: Initially, 30-60mg per day. MAINTENANCE: up to 120mg per day. Hypertension Extended-release:ADULTS, ELDERLY: Initially, 30-60mg per day. MAINTENANCE: up to 120mg per day.

Action of Nifedipine
Nifedipine inhibits calcium ion movement across cell membrane, depressing contraction of cardiac or vascular smooth muscle. It also increases heart rate and cardiac output. Nifedipine decreases systemic vascular resistance and blood pressure.

Side Effects and Adverse Reactions of Nifedipine

Side Effects of Nifedipine

Peripheral edema

o o o o o o o o o o o o o o o o o o o o o o o o o

Headache Flushed skin Dizziness Nausea Shakiness Muscle cramps or pain Drowsiness Palpitations Nasal congestion Cough Dyspnea Wheezing Hypotension Rash Pruritus Urticaria Constipation Abdominal discomfort Flatulence Sexual dysfunction Adverse Reactions of Nifedipine May precipitate Congestive Heart Failure and Myocardial Infarction in patients with cardiac disease and peripheral ischemia. Nausea Drowsiness Confusion Slurred speech

Nursing Considerations for Clients Taking Nifedipine

o o o o o o o o o o
Do not crush or break film-coated tablets and sustained-release capsules. Give without regards to meals Grapefruit juice may alter absorption. Concurrent therapy of sublingual nitroglycerin may be used for relief of anginal pain. Record onset, type, radiation, location, intensity, and duration of anginal pain or precipitating factors. Check blood pressure for hypotension immediately prior to giving medication. Assist with ambulation if client is lightheaded or dizziness occurs. Assess for peripheral edema behind medial malleolus. Assess skin for flushing. Monitor liver enzyme tests.

Patient Teachings for Clients Taking Nifedipine

o o o
Rise slowly from lying to sitting position, dangle legs from bed before standing to reduce hypotensive effect. Contact physician or nurse if irregular heartbeat, shortness of breath, pronounced dizziness, or nausea occurs. Avoid alcohol and grapefruit juice use.

GENERIC NAME FOR NICARDIPINE

Nicardipine HCl 20mg, 30mg; caps.

LEGAL CLASSIFICATION:

Rx
PHARMACOLOGICAL CLASS FOR NICARDIPINE

Calcium channel blocker (dihydropyridine).

MANUFACTURER OF NICARDIPINE

Various generic manufacturers

O o O o O o O o O o O o O o O o O o O o o
INDICATIONS FOR NICARDIPINE

Chronic stable angina.

ADULT DOSE FOR NICARDIPINE

Initially 20mg 3 times daily; adjust at intervals of at least 3 days; max 120mg daily. Severe hepatic impairment: initially 20mg twice daily. Renal insufficiency: 20mg 3 times daily and titrate carefully.
CHILDREN'S DOSING FOR NICARDIPINE

<18yrs: not recommended.

CONTRAINDICATIONS FOR NICARDIPINE

Advanced aortic stenosis.

WARNINGS/PRECAUTIONS FOR NICARDIPINE

Cardiac failure. Acute cerebral infarction or hemorrhage. Hepatic or renal impairment. Measure blood pressure 12 hrs and 8 hrs after dosing. Pregnancy (Cat.C). Nursing mothers: not recommended.
INTERACTIONS FOR NICARDIPINE

Potentiated by cimetidine. Increases serum levels of cyclosporine, possibly digoxin (monitor).

ADVERSE REACTIONS FOR NICARDIPINE

Increased angina, hypotension, flushing, headache, pedal edema, asthenia, dizziness, tachycardia, somnolence, GI upset, insomnia.
NOTES FOR NICARDIPINE

Formerly known under the brand name Cardene.

HOW IS NICARDIPINE SUPPLIED?

Contact supplier.
RELATED DISEASE:

Angina Angina~chronic stable

Drug Study for isosorbide (Isordil)

Isosorbide is a heterocyclic compound derived from glucose and is thus a biofeedstock. Glucose can be hydrogenated to sorbitol, which upon double dehydration gives isosorbide. The picture shown to the right is a simplification, since only one enantiomer is formed from sorbitol. Two medications derived from isosorbide are used to treat angina pectoris: isosorbide dinitrate or isosorbide mononitrate. Other isosorbide-based medicines are used as osmoticdiuretics and for treatment of esophageal varices. Like other nitric oxide donors (see biological functions of nitric oxide), this drug lowers portal pressure by vasodilation and decreasing cardiac output.

DRUG NAME

DRUG ACTION

INDICATION/ DOSAGE

CONTRAINDICATIONS

ADVERSE EFFECTS

DRUG INTERACTIONS

NURSING CONSIDERATIONS

Generic Name: isosorbide

Brand Name: Isordil

Pharmalogical Class: nitrate

Therapeutic Class: antianginal

Reduces cardiac oxygen demand decreasing left ventricular end diastolic pressure (preload) and to a lesser extent,systemic vascular resistance (afterload). Also increases blood flow through the collateral coronary vessels.

Acute anginal attacks; to prevent situations that may cause anginal attacks 5mg/ tab S.L. for chest pain every 15 mins.

Contraindicated in patients hypersensitive to nitrites, head trauma, cerebral hemorrhage or severe anemia. Use cautiously in hypotension.

CNS: headache, throbbing, dizziness, weakness CV: orthostatic hypotension. tachycardia, palpitation, ankle edema, fainting GI: nausea and vomiting Skin: cutaneous vasodilation, flushing

Antihypertensives: possibly increased hypotensive effects. Monitor closely during initial therapy.

Monitor blood pressure and intensity and duration of response to drug. Advise patient to avoid alcoholic beverages; they may produce increased hypotension. Warn patient not to confuse sublingual with oral form. Store in cool place, in tightly closed container, away from light.

Brand Name: Capoten Classification: Angiotensin Converting Enzyme (ACE) Inhibitor, Antihypertensive

Indications Hypertension Management of congestive heart failure (CHF) Reduces the risk of death or development of CHF aftermyocardial infarction (MI) Slows the progression of left ventricular dysfunction into overt heart failure Used to decreased the progression of diabetic neuropathy Mechanism of Action Captopril (Capoten) is an angiotension converting enzyme inhibitor. An Angiotensin-Converting Enzyme converts angiotensin I to angiotensin II. Angiotensin II is a potent endogenous vasoconstrictor substance. ACE inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. It also inactivates the vasodilator bradykinin and other vasodilatory prostaglandins. ACE inhibitors also increase plasma rennin levels and reduce aldosterine levels. This is due to the suppression of the rennin-angiotensinaldosterone system resulting in decreased serum concentrations of angiotensin I and aldosterone. The reduction of angiotensin I leads to decreased aldosterone secretion and as a result small increases in serum potassium may occur along with sodium and fluid loss. Contraindications 1. Hypersensitivity 2. Cross sensitivity among Ace inhibitors 3. Pregnancy 4. Angioedema (hereditary or idiopathic) Use cautiously in 1. Renal impairment 2. Hepatic impairment 3. Hypovolemia 4. Hyponatremia 5. Elderly patients 6. Concurrent diuretic therapy 7. Surgery or anesthesia 8. Lactation 9. Children Side Effects 1. Dizziness or lightheadedness 2. Fatigue 3. Headache 4. Insomnia 5. Weakness or excessive tiredness 6. Cough 7. Hypotension 8. Tachycardia or fast heartbeat 9. Taste disturbances: salty or metallic taste or decreased ability to taste 10. Diarrhea 11. Nausea 12. Proteinuria 13. Hyperkalemia 14. Sore throat 15. Fever 16. Mouth sores 17. Unusual bruising Nursing Management 1. Monitor blood pressure and pulse frequently during initial dose adjustment and periodically during therapy. (for patients treated with hypertension) 2. For patients treated with CHF, monitor weight and assess patient routinely for resolution of fluid overload. Signs of fluid overload are: peripheral edema, rales or crackles, dyspnea, weight gain and jugular vein distention. 3. The nurse should keep in mind that Captopril may cause false-positive result for urine acetone. 4. The drug should be administered 1 hour before or 2 hours after meals. It may be crushed if the patient has difficulty swallowing. 5. Keep this medication in the container it came in, tightly closed, and out of reach of children. 6. Store it at room temperature and away from excess heat and moisture (not in the bathroom). 7. Throw away any medication that is outdated or no longer needed. 8. Inform the patient that Captopril tablets may have a slight sulfur odor (like rotten eggs).

9.

Instruct the patient to notify the physician immediately when the following manifestations are experienced: chest pain swelling of the face, eyes, lips, tongue, arms, or legs difficulty breathing or swallowing fainting rash

neric Name : captopril Brand Names:

Apo-Capto (CAN), Capoten, Gen-Captopril (CAN), Novo-Captopril (CAN), Nu-Capto (CAN)

Classification: ACE inhibitor, Antihypertensive

Pregnancy Category C (first trimester) Pregnancy Category D (second and third trimesters)

Dosage & Route

PO HTN Initial: 12.5 mg twice daily. Maintenance: 25-50 mg twice daily. Max: 50 mg 3 times/day. Heart failure Initial: 6.25-12.5 mg 2-3 times/day. Max: 50 mg 3 times/day. Post MI Start 3 days after MI. Initial: 6.25 mg/day, may increase after several wk to 150 mg/day in divided doses if needed and tolerated. Diabetic nephropathy 25 mg 3 times/day.

Therapeutic actions
Captopril competitively inhibits the conversion of angiotensin I (ATI) to angiotensin II (ATII), thus resulting in reduced ATII levels and aldosterone secretion. It also increases plasma renin activity and bradykinin levels. Reduction of ATII leads to decreased sodium and water retention. By these mechanisms, captopril produces a hypotensive effect and a beneficial effect in congestive heart failure.

Pharmacokinetics

Absorption: 60-75% absorbed from the GI tract (oral); peak plasma concentrations after 1 hr. Absorption may be reduced in the presence of food. Distribution: Protein-binding: 30%; crosses the placenta and enters breast milk at about 1% of maternal blood concentrations. Excretion: Via urine (40-50% as unchanged, the rest as disulfide and other metabolites); 2-3 hr (elimination half-life), may be increased in renal impairment. Removed by hemodialysis.

Indications

Treatment of hypertension alone or in combination with thiazide-type diuretics Treatment of CHF in patients unresponsive to conventional therapy; used with diuretics and digitalis Treatment of diabetic nephropathy Treatment of left ventricular dysfunction after MI

Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema; Bartters syndrome; Raynauds syndrome

Adverse effects

Hypotension, tachycardia, chest pain, palpitations, pruritus, hyperkalemia. Proteinuria; angioedema, skin rashes; taste disturbance, nonproductive cough, headache. Potentially Fatal: Neutropenia, usually occurs within 3 mth of starting therapy especially in patients with renal dysfunction or collagen diseases. Hyperkalaemia. Anaphylactic reactions.

Contraindications

Known hypersensitivity to the drug. Bilateral renal artery stenosis, hereditary angioedema; renal impairment; pregnancy.

Nursing Considerations
Assessment
History: Allergy to captopril, history of angioedema, impaired renal function, CHF, salt or volume depletion, pregnancy, lactation Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, LFTs, renal function tests, CBC and differential

Interventions
Administer 1 hr before meals. WARNING: Ensure that patient is not pregnant before beginning treatment. Encourage use of contraceptives; if pregnancy is detected, stop drug. WARNING: Alert surgeon and mark patients chart with notice that captopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion. Monitor patient closely for fall in BP secondary to reduction in fluid volume (due to excessive perspiration, and dehydration, vomiting, or diarrhea); excessive hypotension may occur. Reduce dosage in patients with impaired renal function.

Teaching points
Take drug 1 hour before meals; do not take with food. Do not stop without consulting your health care provider. Be careful of drop in blood pressure (occurs most often with diarrhea, sweating, vomiting, or dehydration); if light-headedness or dizziness occurs, consult your health care provider. Severe fetal damage can occur if captopril is taken during pregnancy. Use of contraceptives is advised; if pregnancy should occur, stop drug and notify health care provider. Avoid over-the-counter medications, especially cough, cold, allergy medications that may contain ingredients that will interact with ACE inhibitors. Consult your health care provider. You may experience these side effects: Cough, GI upset, loss of appetite, change in taste perception (limited effects, will pass); mouth sores (frequent mouth care may help); rash; fast heart rate; dizziness, light-headedness (usually passes after the first few days; change position slowly, and limit your activities to those that do not require alertness and precision). Report mouth sores; sore throat, fever, chills; swelling of the hands or feet; irregular heartbeat, chest pains;

Terazosin (marketed as Hytrin or Zayasel) is a selective alpha 1 antagonist used for treatment of symptoms of an enlarged prostate (BPH). It also acts to lower the blood pressure, and is therefore a drug of choice for men with hypertension and prostate enlargement.

It works by blocking the action of adrenaline on smooth muscle of the bladder and the blood vessel walls. Most common side effects include dizziness, drowsiness, headache, constipation, loss of appetite, fatigue, nasal congestion or dry eyes, but they generally go away after only a few days of use. Therapy should always be started with a low dose to avoid first dose phenomenon.[1]Sexual side effects are rare, but may include priapism or erectile dysfunction. [edit]References

Brand Name: Osmitrol, Resectisol Classification: Osmotic Diuretic Action Summary Half-life 100 minutes Onset 30-60 minutes Peak 1 hour Duration 6-8 hours

Indications 1. Acute oliguric renal failure 2. Toxic overdose 3. Edema 4. Increased intracranial pressure (ICP) 5. Intraocular pressure (IOP) Action 1. In the oliguric phase of acute renal failure, Mannitol increases osmotic pressure (pressure needed to stop the absorption of something or osmosis) of the glumerular filtrate, thereby,promoting diuresis (treating the oliguric phase of renal failure) and excretes toxic materials (management for toxic overdose). 2. It also elevates blood plasma osmolality thus, inhibiting the reabsorption of water and electrolytes (for relief of edema) and mobilizing fluids in the cerebral and ocular spaces(lowers intracranial or intraocular pressure). Contraindications 1. Susceptibility 2. Dehydration Adverse reactions 1. Dehydration 2. Anuria 3. Intracranial bleeding 4. Headache 5. Blurred vision 6. Nausea and vomiting 7. Volume expansion 8. Chest pain 9. Pulmonary edema 10. Thirst 11. Tachycardia 12. Hypokalemia (increases the risk of digoxin toxicity) 13. Chronic renal failure Dosage Adult Oliguria: 50-100 g as a 5-25% solution. Intracranial/Intraocular pressure: 0.25-2 g/kg as 15-25% solution administered for 30-60 minutes. Children Oliguria: 0.25-2 g/kg as a 15-20% solution for 2-6 hours Intracranial/Intraocular pressure: 1-2 g/kg as a 15-20% solution administered for 30-60 minutes. Nursing considerations Assessment Monitor the following: 1. 1. Vital signs 2. 2. Intake and output 3. 3. Central venous pressure 4. Pulmonary artery pressure 5. Signs and symptoms of dehydration (e.g. poor skin turgor, dry skin, fever, thirst)

6.

Signs of electrolyte imbalance/deficit (e.g. muscular weakness, paresthesia, numbness, confusion, tingling sensation of extremity and excessive thirst) 7. (for increase ICP) Neurologic status and intracranial pressure readings. 8. (for increase IOP) Elevating eye pain or decreased visual acuity. Laboratory Tests 1. Renal function (BUN and Creatinine) 2. Serum Electrolyte (Sodium and Potassium) Precaution Pregnancy and lactation (safe use during these conditions is not established) Interventions 1. Observe the IV site regularly for infiltration. 2. Administration rate for oliguria should be titrated to produce a urine output. (about 30-50 ml/hr in adult and 2-6 hours in children)

Trade Names
Nubain - Injection 10 mg/mL - Injection 20mg/mL Nubain (Canada)

Pharmacology
An opiate analgesic with both narcotic agonist and antagonist actions. Analgesic potency is about equal to that of morphine, and antagonist potency is about 1/ 25 that of naloxone. May cause sphincter of Oddi spasm. Does not increase pulmonary artery pressure, systemic vascular resistance, or myocardial work load.

Pharmacokinetics
Absorption
When nalbuphine is taken orally, it is not as effective for pain relief as when given IM, mainly because of first-pass metabolism in GI and liver. T max is 30 min (IM).

Distribution
Nalbuphine is not bound to plasma proteins. Nalbuphine crosses the placenta.

Metabolism
Metabolized in the liver.

Elimination
Approximately 7% eliminated in urine unchanged and in feces. Plasma t
1/ 2

is 5 h and t 1/ 2 is 2.4 h.

Onset
Onset of IV nalbuphine is 2 to 3 min. Onset of subcutaneous and IM nalbuphine is less than 15 min.

Duration

Duration of analgesic activity is 3 to 6 h.

Indications and Usage

Management of moderate to severe pain; preoperative and postoperative analgesia; supplement to balanced anesthesia; obstetrical analgesia during labor and delivery.

Unlabeled Uses
Prevention and treatment of intrathecal morphine-induced pruritus after cesarean delivery.

Contraindications
Standard considerations.

Dosage and Administration

Adults Subcutaneous / IM / IV 10 mg per 70 kg q 3 to 6 h as needed. Individualize dosage. In nontolerant patients, do not exceed 20mg/dose or 160mg/day.

General Advice

For subcutaneous, IM, or IV administration. Not for intradermal or intra-arterial administration. Do not administer if particulate matter or discoloration noted. Discard any unused medication per institutional policy and procedure. Ensure naloxone, oxygen, and resuscitation and intubation equipment are available for use if needed.

Storage/Stability
Store ampules and vials at controlled room temperature (59 to 86F). Protect from excessive light. Store ampules and vials in carton until contents have been used.