Apollo Headache And Migraine Clinic Research Paper

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Apollo Headache And Migraine Clinic Research Paper

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Albumin can be used in burns after the first hours. Albumin is not the first line therapy for resuscitation, but may be appropriate as a second line solution Liumbruno et al, Given that albumin has some minor risks and is no better than crystalloids for resuscitation, the cost of use is likely not worth any patient benefit in the prehospital setting. Side effects and adverse reactions have been reported with albumin. Allergic-type reactions can occur Laxenaire et al, Rapid infusion can paradoxically drop blood pressure and lead to congestive heart failure, especially in elderly patients or those with pre-existing heart failure.

As with other solutions, albumin should not be administered if the solution appears cloudy or turbid. Contraindications: fluid resuscitation instead of crystalloids, heart failure, renal failure. Black box warning: renal failure, increased risk of bleeding coagulopathy. Starches are colloid solutions that were created to be volume expanders. The idea is that these solutions contain large molecules that will remain in the vessel, similar to albumin but without the risk of blood borne disease. Since they do not require a human donor, starch solutions are aimed at also being cheaper than albumin. Unfortunately, several studies have shown these products to be detrimental and their use is falling out of favor. Renal failure has been associated with the use of starch volume expanders Schortgen et al ; 6S trial, The U.

Food and Drug Administration FDA released a black box warning that these solutions can increase the risk of bleeding. A boxed warning, sometimes called a black box warning, is found on the package insert for certain drugs and is the strongest warning that the FDA requires, indicating that life-threatening adverse effects can occur if the drug is used in these circumstances. Starch solutions have little value and can cause significant patient harm if used for large volume resuscitation in the prehospital setting.

Virtual Mentor: Mobile References Technology has advanced significantly over the past decade to the point where our mobile phones have more powerful technology than the Apollo Guidance Computer that landed astronauts mission to the moon. Creating software applications for mobile devices has become easier as well and there are countless medical applications available. Since drug indications, dosing, and adverse effects can change with time, it is useful to have an up-to-date medical reference.

But with the number of applications available, how do you choose the right one? Look for applications that: are used by a large number of providers, allow for updates to be downloaded, and are written by clinicians. Two examples are Medscape and UpToDate. UpToDate is an evidence-based clinical decision support resource that requires a subscription. The drug information in this chapter is by no means all inclusive. Mobile references can provide complete details about drug indications, adverse effects, and drug interactions. Contraindications: open flame, respiratory insufficiency if ventilation related hypercarbia , high-flow use in certain situations such as preterm infants.

Adverse Effects: drying of skin, absorption atelectasis, masking of hypercarbia. No drug is used more commonly in emergency medical services than oxygen. The indications to use oxygen therapy are too numerous to list here. Major indications for the use of oxygen focus on hypoxia, which is low oxygen levels in the tissues. Hypoxia can be split into several categories, all of which can be managed with oxygen therapy: 1 Low oxygen in the blood hypoxemia , examples include: pulmonary embolism, pneumonia, COPD, hypoventilation from medications e.

In patients with chest pain but no hypoxia, the AHA guidelines do not recommend giving supplemental oxygen. Oxygen in this situation can reduce coronary blood flow and make vasodilating medications less effective. In infants, titration of oxygen therapy is even more critical. As with adults, providing insufficient of excessive oxygen therapy can lead to problems. Preterm infants are at risk for retinal injury with excessive oxygen use. Pulmonary oxygen toxicity has been described in adults, but typically requires high oxygen administration over many hours Clark et al, Some other issues with high flow oxygen are absorption atelectasis, drying of mucous membranes, and combustion.

Absorption atelectasis occurs when nitrogen, from air, in the lungs is washed out by oxygen. The alveoli in the lungs are held open by nitrogen during normal air breathing. When nitrogen is not present, oxygen can cross into the blood resulting in collapse of the alveoli. Drying of the mucous membrane is a minor worry as it can cause pain and potentially increase the risk of membrane bleeding. Oxygen is combustible and poses significant risk for fire when near an ignition source.

Can oxygen be used in COPD patients? A commonly taught dogma in medicine is that COPD patients have a primary hypoxic drive and giving them oxygen will result in hypoventilation and increased CO2 retention hypercapnia. This has been shown to be false Abdo et al, There is no need to withhold oxygen therapy from COPD patients for fear of worsening their respiratory status. One of the most worrisome issues with oxygen administration is the masking of hypercarbia. Respiratory failure is typically divided into two types: Type 1, also known as hypoxemic, and Type 2, also known as hypercarbic.

Hypoxemia respiratory failure is improved with oxygen therapy. Hypercarbic respiratory failure may by masked by oxygen therapy. To illustrate this issue, let us examine a case by Ayas et al. A year-old woman was in the post-anesthesia care unit after hip surgery. Her endotracheal tube was left in place due to inadequate respirations. After 3. This demonstrated that her oxygenation was adequate but her ventilation was so poor that her CO2 level rose to an astounding mmHg in her blood. A pH below 7 is severely acidotic and a pH below 6. Again, assessment of respiratory status requires both oxygenation SpO2 and ventilation ETCO2 ; administering oxygen can fool the provider into thinking there is no respiratory issue if only SpO2 is monitored. The above case also highlights apneic oxygenation.

Apneic oxygenation is the diffusion of oxygen into the alveoli without ventilation. Weigard and Levitan more recently reviewed methods to prevent desaturation during emergency airway management, with a focus on appropriate oxygen therapy. During the apneic period with tracheal intubation attempts, they recommend applying nasal oxygen at 15LPM to assist with apneic oxygenation. Anticholinergic medications act by blocking the neurotransmitter acetylcholine in the peripheral nervous system. This causes inhibition of the parasympathetic nervous system and are therefore also referred to as parasympatholytic medications.

A toxidrome is a syndrome collection of signs and symptoms seen with drug toxicity from a specific class of medications. Anticholinergic syndrome ACS can occur with inadvertent overdose or intentional overdose of anticholinergic medications. The signs and symptoms associated with this syndrome are the same, though to a lesser degree, as the signs and symptoms seen with use of anticholinergic medications. They include skin flushing, dry skin, dry mucous membranes, mydriasis dilated pupils , altered mental status, and fever. Bronchodilator effects can occur and are exploited to cause bronchial smooth muscle relaxation in patients with asthma and other bronchospastic disease.

Indications: chronic obstructive pulmonary disease, acute asthma exacerbation off-label. Contraindications: hypersensitivity to ipratropium or atropine or similar anticholinergics. Adverse Effects: paradoxical bronchospasm, dry mouth, hypersensitivity, urinary retention, bronchospasm in myasthenia gravis, worsening of glaucoma. Drug Interaction: none contraindicated, anticholinergics. Ipratropium is an anticholinergic medication used for patients with chronic obstructive pulmonary disease and during acute asthma exacerbation. In COPD, the inhaler dose is 2 actuations, 4 times per day, to a maximum of 12 actuations per day.

In asthma exacerbation this is changed to 8 actuations every 20 minutes, to a maximum of 3 hours. In the setting of asthma, ipratropium should be given in combination with a short-acting beta-adrenergic SABA agonist medication like albuterol. The brands Duoneb and Combivent are available combinations of ipratropium with albuterol. The nebulized solution is mcg in 2. For COPD, nebulized ipratropium can be given times per day spaced hours apart. In asthma exacerbation, nebulization dose is mcg every 20 minutes for three doses, then as needed. It is worth noting that ipratropium for asthma exacerbation is an off-label use. The drug label on FDA-approved medications explains the medical conditions for which it was approved.

If the drug is not used for the indicated condition, or is used differently dose or route , the use is said to be off-label. Medical evidence typically supports the off-label use of these drugs but the manufacturer of that drug has not done formal testing that is required by the FDA. In the case of ipratropium, there is sufficient medical evidence to warrant its use in the emergency setting NAEPP, Caution should be taken when using ipratropium in the setting of other anticholinergics, such as atropine, since side effects can increase. Common side effects follow with anticholinergic symptoms: dry mouth and urinary retention. Hypersensitivity immune reactions are rare. A hypersensitivity reaction is any of the types of immune reactions, which can range from a mild rash to life-threatening anaphylaxis.

These can occur with most drugs and previous hypersensitivity reaction is a contraindication to the use of any medication. There have been cases of patients with myasthenia gravis who had worsening of their pulmonary status with the use of ipratropium. The mydriasis effect of anticholinergic medications, such as ipratropium, can worsen angle-closure glaucoma and should be avoided in these patients. No major drug interactions warrant avoiding ipratropium in the emergency setting. Beta-1 agonists affect the heart. Beta-2 agonists also result in peripheral vasodilation, which can lead to tachycardia.

Tachycardia with beta agonists can also be secondary to direct cardiac stimulation. This tachycardia can lead to myocardial ischemia and arrhythmias in susceptible individuals, such as those with underlying coronary artery disease. Other side effects include tremors, sweating, anxiety, and agitation. Hyperglycemia can occur with beta-2 agonists due to breakdown of glucose in the liver and release of glucagon from the pancreas. Reduction in serum potassium occurs by moving the potassium into cells from the bloodstream. Beta-2 agonists for pulmonary conditions include albuterol, epinephrine, levalbuterol, racemic epinephrine, and terbutaline. Pharmacokinetics : liver metabolism, urine elimination, half-life 4hr.

Indications: bronchospasm, asthma exacerbation, hyperkalemia. Contraindications: hypersensitivity to albuterol, severe coronary artery disease, severe aortic stenosis. Adverse Effects: tachycardia, hypokalemia, hyperglycemia, seizures, worsening of glaucoma. Drug Interaction: none contraindicated, sotalol. Bronchospasm can be triggered by asthma, anaphylaxis, or tracheal stimulation such as during the placement of an endotracheal tube. Adult dosing for bronchospasm is puffs every hours as needed. Typical inhaler concentration is 90mcg per puff. Albuterol can also be administered into an endotracheal tube via an adapter device or using a 60mL syringe see Figure For acute severe asthma, the dose is puffs every 20 minutes for up to 4 hours. These metered inhaler doses are the same for pediatric patients.

Nebulized albuterol can be given as a single dose or as a continuous infusion. Maximum doses are different for adults and children. For bronchospasm in adults the dose is 2. In children years old the dose is 1. For children older than 12 years old, the dose is 2. Higher doses are used for acute severe asthma exacerbation. In adults with asthma, the dose is 2.

Continuous nebulization dosing is mg per hour, though symptoms such as tremors may limit dosing. For children under 12 years old, the dose is 0. Dosing for children over 12 years old with acute asthma is the same as adults. Albuterol can also be used in the treatment of hyperkalemia Allon et al, Although prehospital laboratory assessment may not be available, clues such as renal failure on dialysis or peaked T-waves on the ECG can suggest hyperkalemia. The typical dose in this situation is 20mg of albuterol nebulized as a single adult dose. This can decrease serum potassium levels by 1.

This does not remove potassium from the body, however. It only temporarily moves potassium into cells, which reduces the risk of cardiac arrhythmias. Patients with severe coronary artery disease are at risk for myocardial ischemia if they become tachycardic. The coronary arteries are primarily perfused during cardiac diastole, which is shortened as the heart rate increases. For this reason, albuterol should be used with caution in these patients. Patients with severe aortic stenosis are also at risk for cardiac ischemia if they become tachycardic.

Hypokalemia low potassium can occur with albuterol, especially during continuous nebulization. Hyperglycemia can occur as well, thus caution should be taken in diabetic patients at risk for hyperglycemia. If continuous nebulization is used in diabetic patients, it would be prudent to assess glucose levels intermittently. Beta-agonists can cause central nervous system stimulation, which can precipitate seizures in patients with seizure disorders.

They can also increase intraocular pressure, thus should be used with caution in patients with glaucoma. Using albuterol in patients who are taking sotalol may lead to atrial fibrillation Vader et al, An oral version of albuterol exists but is not preferred for use in emergencies. Pharmacokinetics : liver metabolism, urine elimination, short half-life.

Indications: acute severe asthma off-label. Contraindications: severe coronary artery disease, severe aortic stenosis. Adverse Effects: tachycardia, hypertension, hypokalemia, hyperglycemia, pallor. Drug Interaction: none contraindicated, cocaine, sodium bicarbonate. In patients with acute severe asthma who are unresponsive to inhaled beta-agonist therapy, epinephrine may be used. Dosing is 0. There is no evidence that subcutaneous epinephrine has advantages over inhaled beta-agonist therapy. Epinephrine has been used intravenously for asthma as a continuous infusion starting at 0. For status asthmaticus, the dose is 0. This dose is the same for children and adults, with a maximum single dose of 0.

Critical Concepts: Epinephrine Dosing Epinephrine is a fantastic, life-saving medication. Unfortunately, dosing comes in different concentrations and is dependent on route of administration. Choosing the wrong concentration can have devastating consequences. Some of the confusion seems to be related to expressing epinephrine as a ratio strength e. When referring to medications, the standard is to state the concentration e. Figure shows different concentrations of epinephrine. The diluted 0.

Lammers et al did a study involving a simulated pediatric anaphylaxis scenario. They found that less than half of prehospital providers gave the correct epinephrine dose via the correct route. In Image , the prefilled syringe is shown as an example concentration that is used by anesthesiologists for patients undergoing cardiac surgery. An intravenous bolus dose of 10mcg can sufficiently increase blood pressure and heart rate during peri-arrest situations for those patients. As a rule, intravenous epinephrine should only be used in a , concentration 1mg in 10mL for patients in cardiac arrest. If the patient has a pulse, the intramuscular or subcutaneous route and dosing should be used. Never administer the , 1mg per mL concentration into a vessel. The provider should weight the risks of causing myocardial ischemia in these patients versus the benefit of treating their underlying disorder e.

Side effects include hypertension, tachycardia, hypokalemia, and hyperglycemia. Life-threatening hypertension and tachycardia can occur in patients who have recently used cocaine. Epinephrine should not be mixed with sodium bicarbonate. Pharmacokinetics : liver metabolism, urine elimination, half-life hr. Indications: bronchospasm, asthma exacerbation off-label. Albuterol is a racemic mixture, meaning it contains both the R and S enantiomers of the drug.

An enantiomer is a chemical, containing the same elemental components, but is a mirror-image when the chemical structure is drawn out. Drugs that are racemic mixtures are sometimes divided into their two enantiomer components, R and S , because one of the components has a more favorable response when administered. Levalbuterol is the R -enantiomer of racemic albuterol, which was created because of possible negative effects from the S -enantiomer. Some studies have shown that levalbuterol has more efficacy than racemic albuterol, while other studies have shown no difference NAEPP, Levalbuterol dosing for bronchospasm is 2 puffs every hours as needed. The nebulized solution dosing is 0.

In children, the dosing is same for the metered dose inhaler MDI but the child should be at least 4 years old. Levalbuterol has off-label evidence for the use in acute severe asthma, where adult dosing is puffs every 20 minutes for up to 4 hours with the inhaler or nebulized as 1. For children with asthma, the inhaler dose is the same and the nebulized dose is 0. Adverse effects are the same as albuterol.

Indications: laryngotracheobronchitis croup. Adverse Effects: worsening of epiglottitis, rebound phenomenon. Drug Interaction: none contraindicated. Racemic epinephrine comes in a 2. This is yet another potentially dangerous concentration of epinephrine that should only be given as an inhaled solution. Dosing for racemic epinephrine in croup patients is 0. This solution is then diluted in 2mL of normal saline before administration. This dosing is for infants and children.

Although some advocate for using a fixed 0. The dose may be repeated every 20 minutes as needed. The potent vasoconstricting effects of epinephrine on the airway mucosa limits the systemic absorption. In children, heart rate may be slightly increased or even reduced during administration. However, the potential for cardiac stimulation exists and inhaled epinephrine is not recommended for lower airway issues, such as bronchospasm or asthma exacerbation NAEPP, Adverse effects are rare and are similar to those seen with subcutaneous epinephrine administration, though to a lesser degree.

There has been a case of myocardial infarction in a child with croup who received racemic epinephrine Butte et al, , thus cardiac monitoring may be warranted. This recommendation against racemic epinephrine for lower airway problems highlights that it is a treatment for upper airway issues. The exception is epiglottitis, where cases have been reported where children rapidly deteriorated after racemic epinephrine Kissoon et al, A rebound phenomenon can occur after croup treatment. Nebulized epinephrine lasts up to two hours, at which point the effect goes away and symptoms can return to baseline.

Although long transport times are not common in EMS, this information is useful at handoff communication. A study by Waisman et al found no difference in croup for patients receiving racemic epinephrine or R -epinephrine, which is more widely available and often less costly. The dose when using R -epinephrine is 0. The dose should be diluted in normal saline up to 5mL and may be repeated every 20 minutes as needed.

Indications: asthma, bronchoconstriction. Contraindications: prolonged management of labor. Adverse Effects: tachycardia, hypokalemia, hyperglycemia, tremors, nervousness. Black box warning : prolonged tocolysis. A tocolytic medication is one that suppresses uterine contractions in an effort to prevent preterm labor. Oral and inhalational formulations exist, but the subcutaneous route is preferred for terbutaline in the management of asthma or bronchoconstriction. Adult dosing is 0. The NAEPP guidelines extend this dosing to a maximum of 3 doses, with a minute period between doses, for a maximum of 0.

For children less than 12 years old, dosing is 0. Nebulized or inhaler SABA medications are first line therapy for asthma and bronchospasm. If unavailable or failed, subcutaneous terbutaline is an option. As a general rule, medication vials for non-oral administration are single patient dose. Meaning, you should not usually need to draw up more than one vial of any medication for a standard dose. If you are drawing up more than one vial, or multiple vials, you should second guess the accuracy of your drug dosing. Terbutaline in particular has a black box warning for the use in early labor.

Prolonged use in these situations has led to adverse effects to the mother: tachycardia, hyperglycemia, hypokalemia with cardiac arrhythmias, and myocardial ischemia. Maternal hyperglycemia can lead to neonatal hypoglycemia after the child is born. After birth, this glucose infusion stops but the child still has a high level of insulin, resulting in hypoglycemia. Asthma is a disease that has three effects on the airway: bronchospasm, mucus production, and inflammation. Corticosteroids act to reduce systemic inflammation and cause immunosuppression. The major acute complications of steroid therapy are hyperglycemia, increased intraocular pressure, and mania. Steroids have a slow onset of action and therefore are not first line therapy for pulmonary emergencies.

Daily inhaled steroids are used in inflammatory pulmonary conditions as part of maintenance therapy. Oral dosing for steroids is common in the clinic and hospital setting. For patients with acute issues, intravenous dosing is more appropriate as it avoids the need for the patient to swallow while dyspneic. Intravenous formulations also have a quicker onset of action. Corticosteroids used in asthma include dexamethasone, hydrocortisone, methylprednisolone. Other corticosteroid options include prednisolone and prednisone.

Steroid dosing can be converted between types by using the following equipotent dosing chart. As an example, 4mg of IV dexamethasone would be equivalent to about mg IV hydrocortisone or about 20mg IV methylprednisolone. Indications: laryngotracheobronchitis croup , airway edema. Contraindications: systemic fungal infection. Adverse Effects: worsening of psychiatric disturbances, worsening of glaucoma, fluid retention, hyperglycemia. Dexamethasone is a corticosteroid with a wide range of uses.

We will focus on the respiratory indications in this section. Pulmonary indications are airway edema and for children with croup. Several routes of administration are available, but IM or IV are preferred for respiratory emergencies. Intravenous onset is more rapid than IM and peak effect is shorter for IV min versus min. Dosing for airway edema is 0. This regimen is typically used in-hospital for extubation management. For croup, dosing is 0.

The duration of drug action or effect depends on several factors. Elimination half-life is only one of many factors. Half-life typically refers to the elimination half-life which is the time it takes for the body to remove half of the drug concentration. Steroids are one example of medication in which the elimination half-life is much different from the duration of drug effect. For dexamethasone, the half-life is less than 6 hours but the duration of action is up to 3 days. The half-life of aspirin in the plasma is 20 minutes but the duration of action is days.

Most sedation induction agents, like propofol and etomidate, have a half-life that is significantly longer than the duration of effect. Duration of action is more important clinically for the EMS provider. Corticosteroids unfortunately have a large number of side effects. The severe side effects of chronic steroid use, such as adrenal insufficiency, will not be discussed. Corticosteroids should not be given if the patient has a known systemic fungal infection. In the acute setting, steroids oppose the action of insulin and cause an increase in glucose output from the liver. Steroids increase intraocular pressure and should be used with caution in patients who have glaucoma. Steroids can also worsen psychiatric conditions, such as bipolar disorder or mania.

Steroids can also trigger mania in patients without a previous psychiatric diagnosis. Fluid retention can be seen with steroid use; thus, caution should be taken in patients in congestive heart failure. There is debate and confusion about the use of steroids in patients with active infection, as the immunosuppression could make it difficult for the body to fight infection. However, steroids are used in a variety of infectious diseases and have mortality benefit in certain circumstances Prasad, Pharmacokinetics : liver metabolism, urine elimination, half-life min. Indications: status asthmaticus. Hydrocortisone is a corticosteroid that is indicated for the management of status asthmaticus. Oral and IM dosing is used for anti-inflammatory indications, but not typically for status asthmaticus.

Adverse effects are the same as other corticosteroids see dexamethasone. Pharmacokinetics : liver metabolism, urine elimination, half-life 3hr. Indications: asthma exacerbation including status asthmaticus, COPD exacerbation off-label. Contraindications: systemic fungal infection, premature infants. Methylprednisolone is a corticosteroid that is indicated for the management of asthma exacerbation. NAEPP dosing for asthma is 7. Some formulations of methylprednisolone contain benzyl alcohol as a preservative, which is contraindicated for use in premature infants. Xanthines are chemical compounds with bronchodilating effects. They also oppose the action of adenosine, which leads to alertness and stimulant effects.

The most widely used xanthine derivative is caffeine. Other xanthine derivatives include aminophylline and theophylline. Pharmacokinetics : liver metabolism, urine elimination, half-life 6hr in adults. Indications: no pulmonary indications — do not use for asthma. Adverse Effects: arrhythmias, tachycardia, hypertension. Aminophylline is a xanthine-derivative that relaxes bronchial smooth muscle, resulting in bronchodilation. Evidence Category A is the highest level and means that randomized controlled trials have been performed and there is a rich body of data supporting the recommendation.

In an emergency department study, aminophylline was found to provide no additional benefit over SABA therapy and increased the number of adverse effects Parameswaran et al, For every patients that got aminophylline in that study, 20 vomited and 15 had arrhythmias or palpitations. The stimulant side effects of xanthines can lead to tachycardia, hypertension, and arrhythmias. They should not be used in patients with severe coronary artery disease or severe aortic stenosis due to the risk of myocardial ischemia.

Case Study: Bronchospasm You are called to the home of a year-old woman with a history of severe asthma. On arrival, you find her in severe respiratory distress with audible wheezing. She is barely able to speak and oxygen therapy is ineffective. You prepare an albuterol nebulizer and the patient attempts to use it, but SpO2 decreases. You prepare for endotracheal intubation. The patient received mg IV propofol and mg IV succinylcholine. The endotracheal tube is passed without issue and you begin to provide positive pressure ventilation. As you ventilate, you notice it is very difficult to squeeze the bag and move the chest. You spray 10 puffs of albuterol into the endotracheal tube, which is minimal effect.

You draw 0. Albuterol is given again with excellent effect. Critical Thinking Questions 1. Why do you think vecuronium did not help this patient in bronchospasm? Why was epinephrine effective in this situation? Why was albuterol ineffective initially, but effective the second time? The renin-angiotensin-aldosterone system RAAS , also known as the renin-angiotensin system RAS , is a mechanism in the body for maintaining blood pressure. The kidneys sense a low blood pressure then release renin, which begins the complex pathway toward increased blood pressure.

Their primary indication in the acute setting is for patients after myocardial infarction Hazinski et al, ACE inhibitors reduce mortality and improve left ventricular dysfunction in patients who have had a myocardial infarction. They are indicated, in oral form, within 24 hours after AMI. Therapy should start with low-dose oral administration, though IV doses are available in some preparations. Generally, they are not started by EMS or in the ED, but instead are started after coronary reperfusion therapy has been completed and blood pressure is stable. Since PO dosing is preferred and no more than a single dose would be given by an EMS provider, pharmacokinetics will not be discussed. Contraindications for ACE inhibitors is are the same for each of the drugs listed.

They should not be used in pregnant patients due to the risk of fetal injury or death black-box warning. They can cause angioedema and thus are contraindicated in this setting. Hypotensive patients, especially if volume depleted, should not receive ACE-I agents. They may worsen renal failure and should be avoided in these patients. They can also lead to hyperkalemia and thus are contraindicated if potassium levels are high. Caution should be taken in patients with aortic stenosis since ACE-I agents can reduce coronary perfusion leading to ischemia.

Common side effects include hypotension, chest pain, palpitations, tachycardia, hyperkalemia, skin rash, and worsening of renal dysfunction. Intravenous enalapril at 1. Beta-adrenergic antagonists are primarily used to reduce heart rate. Labetalol, as well as carvedilol, are exceptions to the rule. Beta blockers specifically block sympathetic action on the heart, depress SA and AV nodes, decrease cardiac conduction, and slow automaticity. Reduction in cardiac output typically results in a decreased blood pressure with these medications.

Reducing heart rate leads to a decrease in myocardial oxygen demand and also an increase in myocardial oxygen supply. For this reason, beta-adrenergic antagonists have a role in angina management. Pharmacokinetics : liver metabolism, urine and feces elimination, half-life hr. Indications: supraventricular tachycardia, postmyocardial infarction, hypertension, angina, atrial fibrillation off-label. Contraindications: bradycardia, cardiogenic shock. Adverse Effects: bronchospasm, bradycardia, hypotension, cardiogenic shock. Drug Interaction: cocaine, epinephrine, calcium-channel blockers, digoxin. Black box warning : avoid abrupt withdrawal. It is typically used in oral form for chronic management of hypertension, angina, and atrial fibrillation. Acute use is limited to supraventricular tachycardia and patients who recently had a myocardial infarction.

However, this step is far enough down the algorithm that patients are typically at the hospital when the decision is made to start beta blockers. In stable narrow-complex tachycardia, rate control is the primary goal. Uncontrolled tachycardia increases myocardial oxygen demand and decrease myocardial oxygen supply. Cardiac ischemia will occur sooner or later, which can lead to cardiac arrest.

For patients in supraventricular tachycardia who are unresponsive to vagal maneuvers and adenosine, the next step is rate control with a beta block or calcium channel blocker Neumar et al, For atenolol, the adult dose is 5mg IV given over 5 minutes. This dose can be repeated in 10 minutes if the arrhythmia persists or reoccurs. This dose can also be used in patients with atrial fibrillation or atrial flutter who have rapid ventricular response.

This is also the regimen used for acute myocardial infarction, where oral dosing follows. Use of oral atenolol for chronic conditions, such as hypertension and angina, is not uncommon. Oral dosing of atenolol for EMS providers is not particularly relevant. Patients may be on these medications at home, which puts them at risk for adverse effects and drug interactions while receiving emergency care. Since beta blockers slow heart rate, they should not be used in patients who are already bradycardic. So, although beta blockers are used for patients after myocardial infarction this is only for those who are hemodynamically stable. For patients in cardiogenic shock, beta blockers are absolutely contraindicated and can lead to further deterioration of the condition.

Beta blockers should be used cautiously or even avoided in patients who are taking medications that decrease heart rate, such as digoxin. The use of beta blockers in patients on calcium channel blockers can lead to asystole. Epinephrine may have reduced effects in patients who are beta blocked, which has implications for management of anaphylaxis. Cocaine toxicity is associated with tachycardia, hypertension, and coronary vasoconstriction. These patients should not be given beta blockers as a resultant unopposed alpha agonist effect can occur, leading to severe hypertension. For patients with chest pain and recent cocaine use, beta blockers can worsen the condition McCord et al, Beta blockers carry a black box warning with regard to abrupt withdrawal from chronic use, as this can lead to myocardial infarction and ventricular arrhythmias.

Pharmacokinetics : red blood cell esterase metabolism, urine elimination, half-life 9min. Indications: supraventricular tachycardia, hypertension, atrial fibrillation or flutter. It is metabolized by red blood cell esterases, so its half-life is not prolonged in renal failure or liver failure. It is available in intravenous form and is typically given as a bolus dose followed by an infusion.

Because of the short half-life, it is a very forgiving medication and can be used in bolus-only form to terminate arrhythmias. For ongoing arrhythmias and hypertension, an infusion is required, which necessitates having an infusion pump available. Adult dosing for supraventricular tachycardia, including atrial fibrillation and flutter, is 0. If the effect is inadequate, a second IV bolus dose of 0. This can be repeated up until a maximum infusion rate of 0. Esmolol is most likely to affect blood pressure if the hypertension is related to the tachycardia, versus low SVR for example. Also, the need for an infusion pump makes this medication less desirable as an option for hypertension management. Contraindications, side effects, and drug interactions are the same as for atenolol and other beta-blockers.

Esmolol is not for chronic use thus there is no black box warning for abrupt withdrawal. Doses higher than 0. Doses larger than 0. Pharmacokinetics : liver metabolism, urine elimination, half-life 6hr. Indications: acute hypertension. Contraindications: bradycardia, cardiogenic shock, asthma, hypotension. Labetalol is a beta-blocker available in oral and intravenous form that is different from most other beta blockers. The alpha:beta ratio is in oral form and in intravenous form, meaning labetalol has 7 times more beta-blocking effect than alpha-blocking effect when given IV MacCarthy et al, Labetalol is an option for oral hypertension management in adults, thus patients may present who are this therapy.

In oral form, the half-life is about hours. In IV form, the half-life is typically shorter but can be up to 18 hours depending on the dose and duration of infusion. Contrasting this with esmolol, one can see this is a much less forgiving medication as side effects can last significantly longer. AHA guidelines for the management of adult stroke include measures to control arterial hypertension in acute ischemic stroke patients who are potential candidates for acute reperfusion therapy e. Labetalol dosing for these patients is mg IV given over minutes, which may be repeated once Jauch et al, If reperfusion therapy has started e. Another option is nicardipine, discussed later in this chapter.

For hypertensive emergency or urgency, manufacturer dosing is a more aggressive. They recommend an initial 20mg IV bolus over 2 minutes, which may be increased to mg given in 10 minute intervals, to a maximum of mg. Pediatric dosing is off-label, but intermittent boluses of 0. For pediatric hypertensive emergency, dosing is 0. Contraindications, side effects, and drug interactions are the same as for other beta-blockers. Patients who are hypovolemic are at risk for significant hypotension with labetalol since they have limited ability to improve cardiac output.

Epinephrine is less effective in a patient taking labetalol, thus increased doses may be needed for emergency situations such as anaphylaxis. Using the standard dosing regimen first is appropriate, but one should keep in mind that additional dosing may be needed in these patients. Labetalol would seem like an attractive choice for hypertension and tachycardia associated with cocaine intoxication, since unopposed alpha effects are less likely when compared with the beta-specific blockers. Unfortunately, labetalol does not appear to offer any advantages in acute cocaine intoxication McCord et al, In animal studies, labetalol increased the risk of seizures and death with cocaine toxicity.

In adult studies, labetalol did not reverse coronary artery vasoconstriction with cocaine toxicity. Indications: supraventricular tachycardia, postmyocardial infarction, hypertension, angina, atrial fibrillation, atrial flutter. Oral use is typically for chronic conditions including angina, heart failure, atrial fibrillation, hypertension, and after myocardial infarction. Acute conditions where the intravenous form can be used include supraventricular, hypertension, and after acute myocardial infarction. For supraventricular tachycardia unresponsive to vagal maneuvers and adenosine, dosing is 5mg over min, which can be repeated every 5 minutes to a maximum of 15mg. For hypertension or ventricular rate control e. In acute myocardial infarction, without cardiogenic shock, metoprolol 5mg IV may be given every 5 minutes up to 3 doses in hypertensive patients who have ongoing ischemia.

As with other beta-blockers, caution is needed in heart failure as reducing contractility can worsen the condition. Acute supraventricular tachycardia in patients who have beta-blocker contraindications, such as heart failure, can be managed with cardioversion January et al, The same black box warning applies for metoprolol as it does for other oral beta-blockers, where abrupt withdrawal can lead to myocardial infarction.

Pharmacokinetics: liver metabolism, urine elimination, half-life 4hr. Indications: supraventricular tachycardia, postmyocardial infarction, hypertension. Contraindications: bradycardia, cardiogenic shock, asthma. Oral formulation has similar indications are previously mentioned beta-blockers plus several other indications for chronic condition such as essential tremor, migraine prophylaxis, and esophageal bleeding prophylaxis for liver patients.

IV dosing for adult supraventricular tachycardia is 0. For children, use for tachycardia is off-label and dosing range is 0. Contraindications, side effects, drug interactions, and black box warning are the same as for other beta-blockers. This makes propranolol a less desirable choice for tachycardia management when compared with atenolol, esmolol, or metoprolol. Pain during acute coronary syndrome is secondary to the supply-demand mismatch of the heart, where oxygen supply cannot reach myocardial demand. Medications that improve this mismatch will help relieve chest pain symptoms. Examples are antianginal agents like nitroglycerin and beta-blockers, as they reduce heart rate which improve supply and decreases demand.

Opioid analgesics may have a role in the management of pain during cardiovascular emergencies, but caution should be taken. Opioids effect the sensation of pain but do not always improve the cause of the pain. There is potential for false reassurance that the underlying disorder is improved just because the patient is in less pain. Pharmacokinetics : liver metabolism, urine elimination, half-life 90min.

Indications: chest pain with acute coronary syndrome. Contraindications: altered mental status, severe respiratory depression, acute or severe asthma, known paralytic ileus. Adverse Effects: apnea, sedation, confusion, hypotension, flushing, bradycardia, histamine release, anticholinergic effects, constipation, nausea, miosis, itching, muscle rigidity, potential for abuse, worsening of hypotension with right ventricular infarction, worsening of hypotension in volume-depleted patients. Drug Interaction: sedatives and analgesics including ethanol.

Black box warning: respiratory depression. Morphine is an opioid analgesic first discovered in the year It is widely available in generic format for PO and IV use, however there are several name brand formulations for other routes of administration. Morphine is the prototypical opioid used for comparison to other opioids. For ACS patients unresponsive to nitrates or in acute cardiogenic pulmonary edema with adequate blood pressure, dosing is mg IV.

Additional doses of mg IV may be given at minute intervals, noting that the onset takes at least 5 minutes. Opioids have many effects on different parts of the body. They relieve pain by several mechanisms and have both supraspinal brain and spinal analgesic effects. They can lead to sedation and euphoria, but generally do not cause loss of consciousness. They have cough suppressant effects and are used widely for this purpose in the outpatient setting. Their cardiovascular effects include bradycardia and some vasodilation.

Histamine release is associated with the vasodilation and pruritus. They cause miosis, delayed gastric emptying, ileus with constipation, and urinary retention. If a patient is known to have severe constipation, opioids should be avoided or used cautiously. Most importantly, they depress ventilation and can lead to apnea. For this reason, they should be avoided or at least used cautiously in patients with severe respiratory depression, including severe asthma, as well as patients with altered mental status. Morphine has several black box warnings, but most of the warnings are for specialty formulations of the drug. The most important black box warning, which applies to all morphine formulations, is respiratory depression. Respiratory depression is the leading cause of death from overdose of morphine and other opioid medications.

Providers must be prepared to manage the airway of any patient receiving sedatives and analgesics. Opioids should be used with caution when the patient has taken or received other analgesics or sedatives, including ethanol. These substances are additive i. Some combinations are synergistic, meaning their combined effect is higher than each drug would cause alone i. Although this is a standard regimen, one must know about the contraindications and details of each of these medications.

Morphine has some contraindications and cautions, as previously mentioned. Aspirin contraindications will be discussed later in this chapter. Several antianginal agents exist and are typically divided into nitrates, beta blockers, and calcium channel blockers. Nitrates, such as nitroglycerin, have the largest effect on preload thus should be used cautiously in patients who depend on their cardiac preload e. Patients at risk for cardiac ischemia may be on nitrates at home and are typically instructed to call for EMS if their pain is either unrelieved or increased after a single rescue dose. Pharmacokinetics : liver metabolism extensive first pass , urine elimination, half-life min.

Indications: ischemic chest pain, hypertension, uterine relaxation off-label. Contraindications: hypotension especially with tachycardia, severe bradycardia, right ventricular infarction, use with phosphodiesterase inhibitors. Adverse Effects: hypotension, increased intracranial pressure, paradoxical bradycardia, tachycardia, hypertrophic cardiomyopathy, methemoglobinemia rare. Drug Interaction: phosphodiesterase inhibitors. Nitroglycerin is the initial antianginal of choice for suspected ischemic chest pain. It is available in several formulations including sublingual tablets, aerosol spray, topical paste, transdermal patch, and intravenous fluid.

Nitroglycerin relaxes vascular smooth muscle, causing more venous dilation than arterial dilation. The mechanism is similar to nitroprusside in that it metabolizes to nitric oxide, which causes vasodilation. Nitroglycerin dilates coronary vessels, but despite this there is no conclusive evidence that it should be used routinely in AMI. Nitrates can be given for ischemic chest pain in up to 3 doses, given min apart. Topical nitrates e. In patients with obvious acute coronary syndrome or ongoing ischemia, an intravenous infusion may be used. Dosing is This is considered the route of choice for emergencies.

Topical formulations typically take min for onset, 60min for peak, and last about 7 hours. Patients may present wearing transdermal patches, which should be left on unless they are causing undesired effects e. Intravenous onset is immediate with immediate peak, but duration of action is min so effects quickly stop after stopping the infusion. Preload reduction makes nitroglycerin a good choice for cardiogenic pulmonary edema. Nitroglycerin improves myocardial oxygen supply and reduces demand through several mechanisms including reduced venous return, reduced preload, and relief of coronary vasospasm. Hypotension is a side effect that can preclude the use of other beneficial agents, such as angiotensin converting enzyme ACE inhibitors.

Patients taking phosphodiesterase inhibitors, such as sildenafil for erectile dysfunction, should not receive nitrates due to risk for severe hypotension. Compensatory tachycardia may be seen with the drop in preload and SVR, thus caution should be taken in patients who are already tachycardic as further tachycardia will reduce myocardial oxygen supply and increase demand. Patients with hypertrophic cardiomyopathy HOCM have cardiac outflow tract obstruction and thus depend on adequate preload to reduce this obstruction. Giving nitroglycerin to these patients worsens their obstruction by reducing preload.

If tachycardia occurs, this further reduces the time for the heart to fill and can lead to cardiac arrest in HOCM patients. Uterine relaxation is a side effect of nitroglycerin, thus it should be avoided in patients with significant vaginal bleeding especially if they are pregnant. On arrival you find a large diaphoretic man who is gripping his chest. You have your partner obtain an ECG as you obtain a medical history. The patient has known coronary disease and is taking a beta blocker for hypertension. You determine that the patient is not taking any medications for erectile dysfunction then administer 0.

The patient reports no relief and remains uncomfortable with crushing chest pain. You ask EMT Yoo to obtain vital signs, but she is busy talking with dispatch to have the hospital activate their cardiac catheterization team. Heart rate and SpO2 are unchanged. You administer 5mg IV morphine for the ongoing chest pain. You act quickly to obtain another IV, this time larger gauge, and hang fluids wide open. Nitrates and morphine are contraindicated in patients with right ventricular infarction. The right ventricle needs adequate preload to pump, and preload is reduced with these medications.

It should be suspected in any patient with hypotension and an inferior wall infarction on ECG. Hypotension in this setting should be initially treated with IV fluids. Diuretics and other vasodilators, such as ACE inhibitors, should also be avoided due to the risk for severe hypotension. Arrhythmias are treated in three different ways: mechanically e. Ventricular arrhythmias and more serious arrhythmias typically require immediate electrical therapy. Pharmacologic therapy can both improve arrhythmias and prevent their reoccurrence.

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