15 Emergency Drugs
This chapter includes some of the drugs used in emergencies such as cardiac arrest, anaphylaxis and eclampsia (see Chapters 16 and 17 for drugs for haemorrhage).
Drugs Used in the Treatment of Cardiac Arrest
NB: Atropine is no longer recommended in the treatment of asystole or pulseless electrical activity.
BP
Adrenaline (epinephrine)
Proprietary
Cardiac arrest
Adrenaline (Epinephrine) 1 : 10 000 Sterile Solution Minijet® (International Medication Systems (UK) Ltd)
Anaphylaxis
Adrenaline (Epinephrine) Injection BP 1 in 1000 (Hameln Pharmaceuticals Ltd)
Adrenaline (Epinephrine) 1 : 10 000 Sterile Solution Minijet® (International Medication Systems (UK) Ltd)
Anaphylaxis
Adrenaline (Epinephrine) Injection BP 1 in 1000 (Hameln Pharmaceuticals Ltd)
Group
Cardiopulmonary resuscitation, allergic emergencies
Uses/indications
Asystolic cardiac arrest in conjunction with calcium chloride and defibrillation. Increases cardiac output and force of contractility by producing generalized vasoconstriction by acting on vascular smooth muscle
anaphylactic shock or severe allergic reactions
anaphylactic shock or severe allergic reactions
Type of drug
POM
Presentation
Minijet, ampoules, auto-injector, prefilled pen, prefilled syringe
Dosage
Cardiac arrest:
Adrenaline (Epinephrine) 1 : 10 000:
Sodium Chloride 0.9% injection: 20 mL peripherally must be administered following adrenaline to aid entry into the central circulation (BNF 62, 2011)
Anaphylactic shock:
Adrenaline Injection BP 1/1000: 500 mcg (0.5 mL adrenaline 1/1000). May be repeated several times at 5-min intervals according to blood pressure, pulse and respiratory function
Adrenaline (Epinephrine) 1 : 10 000:
Sodium Chloride 0.9% injection: 20 mL peripherally must be administered following adrenaline to aid entry into the central circulation (BNF 62, 2011)
Anaphylactic shock:
Adrenaline Injection BP 1/1000: 500 mcg (0.5 mL adrenaline 1/1000). May be repeated several times at 5-min intervals according to blood pressure, pulse and respiratory function
Route of admin
Cardiac arrest: Adrenaline (Ephedrine) 1 : 10 000 – IV (if administered via a central line must not interrupt CPR), intracardiac injection or intraosseous route
Anaphylaxis: Adrenaline Injection BP 1/1000 – S.C./IM/IV (UK Resuscitation Council, 2010, recommends IM)
Anaphylaxis: Adrenaline Injection BP 1/1000 – S.C./IM/IV (UK Resuscitation Council, 2010, recommends IM)
NB: the needle used needs to be long enough to ensure that adrenaline is injected into the muscle; IV use restricted to specialists
Contraindications
Cardiac arrest: Adrenaline (Epinephrine) 1 : 10 000
Contraindications are relative as this product is intended for use in life-threatening emergencies
other than in the emergency situation, the following contraindications should be considered: hyperthyroidism, hypertension, ischaemic heart disease, diabetes mellitus and closed-angle glaucoma
Anaphylaxis: Adrenaline Injection BP 1/1000
Use during labour
With local anaesthesia of peripheral structures including digits, ear lobe
In the presence of ventricular fibrillation, cardiac dilatation, coronary insufficiency, organic brain disease or atherosclerosis, except in emergencies where the potential benefit clearly outweighs the risk
If the solution is discoloured
Contraindications are relative as this product is intended for use in life-threatening emergencies
other than in the emergency situation, the following contraindications should be considered: hyperthyroidism, hypertension, ischaemic heart disease, diabetes mellitus and closed-angle glaucoma
Anaphylaxis: Adrenaline Injection BP 1/1000
Use during labour
With local anaesthesia of peripheral structures including digits, ear lobe
In the presence of ventricular fibrillation, cardiac dilatation, coronary insufficiency, organic brain disease or atherosclerosis, except in emergencies where the potential benefit clearly outweighs the risk
If the solution is discoloured
Side effects
Ventricular fibrillation may occur and severe hypertension may lead to cerebral haemorrhage and pulmonary oedema
Symptomatic adverse effects are anxiety, dyspnoea, restlessness, palpitations, tachycardia, anginal pain, tremor, weakness, dizziness, headache and cold extremities
Biochemical effects include inhibition of insulin secretion, stimulation of growth hormone secretion, hyperglycaemia (even with low doses), gluconeogenesis, glycolysis, lipolysis and ketogenesis
Symptomatic adverse effects are anxiety, dyspnoea, restlessness, palpitations, tachycardia, anginal pain, tremor, weakness, dizziness, headache and cold extremities
Biochemical effects include inhibition of insulin secretion, stimulation of growth hormone secretion, hyperglycaemia (even with low doses), gluconeogenesis, glycolysis, lipolysis and ketogenesis
Interactions
The effects of adrenaline may be potentiated by tricyclic antidepressants
Volatile liquid anaesthetics such as halothane increase the risk of adrenaline-induced ventricular arrhythmias and acute pulmonary oedema if hypoxia is present
Severe hypertension and bradycardia may occur with non-selective beta-blocking drugs such as propranolol Propranolol also inhibits the bronchodilator effect of adrenaline
Risk of cardiac arrhythmias is higher when adrenaline is given to patients receiving digoxin or quinidine
Risk of hypertensive crisis with MAOIs
Adrenaline-induced hyperglycaemia may lead to loss of blood-sugar control in diabetic patients treated with hypoglycaemic agents
The vasoconstrictor and pressor effects of adrenaline, mediated by its α-adrenergic action, may be enhanced by concomitant administration of drugs with similar effects, such as ergot alkaloids or oxytocin
Adrenaline specifically reverses the antihypertensive effects of adrenergic neurone blockers with the risk of severe hypertension
Severe hypertension and bradycardia may occur with non-selective beta-blocking drugs such as propranolol Propranolol also inhibits the bronchodilator effect of adrenaline
Risk of cardiac arrhythmias is higher when adrenaline is given to patients receiving digoxin or quinidine
Risk of hypertensive crisis with MAOIs
Adrenaline-induced hyperglycaemia may lead to loss of blood-sugar control in diabetic patients treated with hypoglycaemic agents
The vasoconstrictor and pressor effects of adrenaline, mediated by its α-adrenergic action, may be enhanced by concomitant administration of drugs with similar effects, such as ergot alkaloids or oxytocin
Adrenaline specifically reverses the antihypertensive effects of adrenergic neurone blockers with the risk of severe hypertension
Pharmacodynamic properties
Adrenaline is a naturally occurring catecholamine secreted by the adrenal medulla in response to exertion or stress. It is a sympathomimetic amine and a potent stimulant of both α- and β-adrenergic receptors
Rapid relief of hypersensitivity reactions to allergies or to idiopathic or exercise-induced anaphylaxis
Has a strong vasoconstrictor action through α-adrenergic stimulation, which counteracts the vasodilatation and increased vascular permeability leading to loss of intravascular fluid and subsequent hypotension, the major features in anaphylactic shock
Stimulates bronchial β-adrenergic receptors and has a powerful bronchodilator action
Alleviates pruritus, urticaria and angio-oedema associated with anaphylaxis
Rapid relief of hypersensitivity reactions to allergies or to idiopathic or exercise-induced anaphylaxis
Has a strong vasoconstrictor action through α-adrenergic stimulation, which counteracts the vasodilatation and increased vascular permeability leading to loss of intravascular fluid and subsequent hypotension, the major features in anaphylactic shock
Stimulates bronchial β-adrenergic receptors and has a powerful bronchodilator action
Alleviates pruritus, urticaria and angio-oedema associated with anaphylaxis
In resuscitation procedures it is used to increase the efficacy of basic life supportIncreased systolic blood pressure, reduced diastolic pressure (increased at higher doses), tachycardia, hyperglycaemia and hypokalaemia
Fetal risk
Crosses the placenta. There is some evidence of a slightly increased incidence of congenital abnormalities
Injection of adrenaline may cause anoxia, fetal tachycardia, cardiac irregularities, extrasystoles and louder heart sounds
Usually inhibits spontaneous or oxytocin-induced contractions of the uterus and may delay the second stage of labour; if uterine contractions are reduced there may be uterine atony with haemorrhage
Parenteral adrenaline should not be used during the second stage of labour
Injection of adrenaline may cause anoxia, fetal tachycardia, cardiac irregularities, extrasystoles and louder heart sounds
Usually inhibits spontaneous or oxytocin-induced contractions of the uterus and may delay the second stage of labour; if uterine contractions are reduced there may be uterine atony with haemorrhage
Parenteral adrenaline should not be used during the second stage of labour
Breastfeeding
Secreted in breast milk and should be avoided
BP
Amiodarone hydrochloride
Proprietary
Amiodarone Hydrochloride 50 mg/mL Concentrate for Solution for Injection/Infusion (Hameln Pharmaceuticals Ltd)
Amiodarone Injection Minijet 30 mg/mL (International Medication Systems (UK) Ltd)
Amiodarone (non-proprietary, see BNF for details)
Amiodarone Injection Minijet 30 mg/mL (International Medication Systems (UK) Ltd)
Amiodarone (non-proprietary, see BNF for details)
Group
Cardiac arrhythmias
Uses/indications
Severe rhythm disorders not responding to other therapies or when other treatments cannot be used
Type of drug
POM
Presentation
Solution for injection
Dosage
IV amiodarone 300 mg (from a prefilled syringe or diluted in 20 mL glucose 5%) should be considered after adrenaline to treat ventricular fibrillation or pulseless ventricular tachycardia in cardiac arrest refractory to defibrillation
An additional dose of amiodarone 150 mg can be given by IV injection if necessary, followed by an IV infusion of amiodarone 900 mg over 24 h (BNF, 2011)
An additional dose of amiodarone 150 mg can be given by IV injection if necessary, followed by an IV infusion of amiodarone 900 mg over 24 h (BNF, 2011)
Route of admin
IV
Contraindications
Hypersensitivity to any of the excipients, e.g. iodine
Infants and children up to 3 years old
Severe respiratory failure, circulatory collapse, or severe arterial hypotension; hypotension, heart failure and cardiomyopathy are also contraindications if 50 mg/mL is given as a bolus injection
Evidence or history of thyroid dysfunction or cardiac conditions
NB: the above contraindications do not apply if cardiac arrest
Infants and children up to 3 years old
Severe respiratory failure, circulatory collapse, or severe arterial hypotension; hypotension, heart failure and cardiomyopathy are also contraindications if 50 mg/mL is given as a bolus injection
Evidence or history of thyroid dysfunction or cardiac conditions
NB: the above contraindications do not apply if cardiac arrest
Side effects
Infusion phlebitis, bradycardia, hypotension
Interactions
Due to the long and variable half-life of amiodarone (approximately 50 days), potential for drug interactions exists not only with concomitant medication but also with drugs administered after discontinuation of amiodarone
Warfarin, phenytoin, digoxin and any drug that prolongs the QT interval
Warfarin, phenytoin, digoxin and any drug that prolongs the QT interval
Pharmacodynamic properties
A membrane-stabilizing antiarrhythmic drug that increases the duration of the action potential and refractory period in atrial and ventricular myocardium
Fetal risk
Crosses placental barrier
Most frequent complications include impaired growth, preterm birth and impaired function of the thyroid gland
Some evidence of hypothyroidism, bradycardia and prolonged QT intervals, increased thyroid gland or cardiac murmurs
Malformation does not appear to be increased, although cardiac defects need to be considered
Given the long half-life of amiodarone, women of childbearing age would need to plan for a pregnancy starting at least half a year after finishing therapy, in order to avoid exposure of the embryo/fetus during early pregnancy
Most frequent complications include impaired growth, preterm birth and impaired function of the thyroid gland
Some evidence of hypothyroidism, bradycardia and prolonged QT intervals, increased thyroid gland or cardiac murmurs
Malformation does not appear to be increased, although cardiac defects need to be considered
Given the long half-life of amiodarone, women of childbearing age would need to plan for a pregnancy starting at least half a year after finishing therapy, in order to avoid exposure of the embryo/fetus during early pregnancy
Breastfeeding
If therapy is required during the lactation period or if taken during pregnancy, breastfeeding should be stopped
BP
Lidocaine
Proprietary
Lidocaine Hydrochloride Injection BP Minijet 1% w/v (International Medication Systems (UK) Ltd)
Lidocaine (non-proprietary, see BNF for details)
Lidocaine (non-proprietary, see BNF for details)
Group
Cardiac arrhythmias
Uses/indications
An alternative but only if amiodarone unavailable
After acute myocardial infarction it suppresses ventricular arrhythmias and reduces the potential for fibrillation and its recurrence. It decreases myocardial contractility and arterial blood pressure, and can be used where there is persistent ventricular fibrillation or ventricular tachycardia
After acute myocardial infarction it suppresses ventricular arrhythmias and reduces the potential for fibrillation and its recurrence. It decreases myocardial contractility and arterial blood pressure, and can be used where there is persistent ventricular fibrillation or ventricular tachycardia
Presentation
Minijet (Lidocaine Hydrochloride BP 10 mg/mL)
Dosage
100 mg as a bolus over a few minutes (reduced to 50 mg in lighter patients), followed by an infusion of 4 mg/min for 30 min, 2 mg/min for 2 h, then 1 mg/min; reduce concentration further if infusion continued beyond 24 h (ECG monitoring and specialist advice for infusion) (see BNF 2011 for guidance)
Route of admin
IV
Contraindications
Hypersensitivity to local anaesthetics of the amide type and in patients with porphyria
NB: continuous ECG monitoring is necessary during IV administration. Resuscitative equipment and drugs should be available immediately for the management of severe adverse cardiovascular, respiratory or central nervous system effects
CAUTION: epilepsy, liver disease, congestive heart failure, severe renal disease, marked hypoxia, severe respiratory depression, hypovolaemia or shock, and in patients with any form of heart block or sinus bradycardia. Hypokalaemia, hypoxia and disorders of acid–base balance should be corrected before treatment with lidocaine begins
NB: continuous ECG monitoring is necessary during IV administration. Resuscitative equipment and drugs should be available immediately for the management of severe adverse cardiovascular, respiratory or central nervous system effects
CAUTION: epilepsy, liver disease, congestive heart failure, severe renal disease, marked hypoxia, severe respiratory depression, hypovolaemia or shock, and in patients with any form of heart block or sinus bradycardia. Hypokalaemia, hypoxia and disorders of acid–base balance should be corrected before treatment with lidocaine begins
Side effects
Allergic reactions (including anaphylaxis)
Light-headedness, drowsiness, dizziness, apprehension, nervousness, euphoria, tinnitus, blurred or double vision, nystagmus, vomiting, sensations of heat, cold or numbness, twitching, tremors, paraesthesia, convulsions, unconsciousness, respiratory depression and arrest, hypotension, cardiovascular collapse and bradycardia which may lead to cardiac arrest
Light-headedness, drowsiness, dizziness, apprehension, nervousness, euphoria, tinnitus, blurred or double vision, nystagmus, vomiting, sensations of heat, cold or numbness, twitching, tremors, paraesthesia, convulsions, unconsciousness, respiratory depression and arrest, hypotension, cardiovascular collapse and bradycardia which may lead to cardiac arrest
Interactions
Propranolol and cimetidine may reduce the renal and hepatic clearance of lidocaine resulting in increased toxicity. The cardiac depressant effects of lidocaine are additive to those of other antiarrhythmic agents. Lidocaine prolongs the action of suxamethonium
Pharmacodynamic properties
Reduces automaticity by decreasing the rate of diastolic (phase 4) depolarization. Lidocaine is considered as a class 1b (membrane stabilizing) antiarrhythmic agent. The duration of the action potential is reduced due to the blockade of the sodium channel and the refractory period is shortened
Fetal risk
Safety has not been established, use if benefit outweighs risk
Breastfeeding
Caution as excreted in breast milk
BP
Sodium bicarbonate
Proprietary
Sodium Bicarbonate Injection BP Minijet 4.2% w/v (International Medication Systems (UK) Ltd)
Sodium Bicarbonate Injection BP Minijet 8.4% w/v (International Medication Systems (UK) Ltd)
Sodium Bicarbonate Intravenous Infusion (non-proprietary, see BNF for details)
Sodium Bicarbonate Injection BP Minijet 8.4% w/v (International Medication Systems (UK) Ltd)
Sodium Bicarbonate Intravenous Infusion (non-proprietary, see BNF for details)
Group
IV fluid
Uses/indications
Correction of metabolic acidosis associated with cardiac arrest after other resuscitative measures, e.g. cardiac compression, ventilation, adrenaline and antiarrhythmic agents, have been used
Type of drug
POM
Presentation
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