EMERGENCY DRUGS

USED IN ORAL SURGERY

R.ANIL KUMAR

4TH BDS

CONTENTS * Introduction

* Classification of the emergency drugs

* Individual emergency drug

* Drug interactions

EMERGENCY DRUGS USED IN ORAL SURGERY

1. Adrenaline 11. Pancuronium bromide

2. Atropine 12. Styptochrome

3. Dopamine 13. Ethamsylate

4. Metoclopramide 14. Ketorolac

5. Phenaramine maleate 15. Aminophylline

6. Hydrocortisone 16. Succinyl choline

7. Dexamethasone 17. Dextrose

8. Diazepam 18. Sodium bicarbonate

9. Fortwin-pentazocin 19. Calcium gluconate

10. Furosemide 20. Chlorphenaramine maleate

CLASSIFICATION

Emergency drugs

Injectables Non Injectables Oxygen

Vasodilators

Respiratory stimulants

Anti Hypoglycaemic agents

Bronchodilators

Primary Secondary Drug for advanced cardiac life support

1) Adrenaline 1) Analgesic 1) Lidocaine

2) Antihistamine 2) Vasopressor 2) Atropine

3) Anti convulsant 3) Corticosteroid 3) Sodium bicarbonate

4) Narcotic antagonist 4) Antihypoglycaemic

ADRENALINE INTRODUCTION :

- It is an adrenergic drug.

- It increases heart rate,force of contraction and cardiac output.

- It constricts blood vessels.

- It increases mean BP.

- Potent bronchodilator

- It causes mydriases in eye that is pupil dilatation.

INDICATIONS :

- Anaophylactic shock

- In bronchial asthma

- In cardiac arrest

- With local anaesthesia

- To control post extraction haemorrhage

- To treat open angle glaucoma

CONTRAINDICATIONS

- Hypersensitivity

- Hyperthyroidism

- Hypertension

- Angina pectoris

- Diabetes mellitus

TRADE NAME : Adrenor, Asmotone

DOSAGE : 0.2-0.5 mg s.c , 0.5 % aerosol

in case of im /iv – in conc of 1:10,000 to 1:1,00,000

ADVERSE EFFECTS

- Marked increase in BP

- photosensitivity, skin rashes

- palpitation, arrythmias

-anginal pain, ventricular failure

ATROPINEINTRODUCTION

- It is a parasympathetic drug

-Anticholinergic action

- Antispasmodic action

- Antisecretory action

- Anti muscarinic action

- It causes tachycardia

- Anti dote for organo phosphate poisoning.

INDICATIONS

- Motion sickness

- Colics and dysmenorrhoea

- Anti parkinsonism

- Pre operatively to reduce secretions & salivation

- In bronchial asthma

- Severe sinus bradycardia

CONTRAINDICATIONS

- Hypersensitivity to belladona alkaloid

- Glaucoma

- Prostatic hypertrophy

- Cardiac failure

- Thyrotoxicosis

TRADE NAME : Atro, Tropine, Atropine sulphate

DOSAGE : Children : oral – 0.2 mg/kg

inj --0.3-0.6 mg i.m

Adults : 0.6- 2 mg/ml i.m

ADVERSE EFFECTS

- Dry mouth, decreased salivation

- Decreased sweating

- Constipation

- Tachycardia, palpitations, arrythmias

- Mydriasis and cycloplegia

DOPAMINEINTRODUCTION

- Potent sympathomimetic agent

- Agonist for dopamine receptors in CNS,renal and other vascular beds

- Agonist for beta adreno receptors in heart

- At high doses it causes vasoconstriction

- At low doses it causes increase in renal blood flow, GFR, and sodium excretion.

INDICATIONS

- Cardiogenic shock

- Septic shock

- Septicaemia

- Congestive heart failure

- Renal failure

- Heart failure

- In parkinsonism

CONTRAINDICATIONS

- Atrial/venticular tachy arrythmias

- Hyperthyroidism

- Pheochromocytoma

TRADE NAMES : Dopamine, Dopinga, Dopapins, Dopar, Dopat.

DOSAGE : Children – 2-20 microgram/kg/min i.v

Adults -- 2-50 micrograms/kg/min i.v

ADVERSE EFFECTS

- Nausea , vomitting

- Tachycardia

- Palpitation

- Anginal pain

- Atopic beats

METOCLOPRAMIDE INTRODUCTION

- It is a pro kinetic drug -- causes forward propulsion of contents of stomach

- Centrally acting dopamine antagonist

- Acts on chemoreceptor trigger zone

- Peripherally acts to enhance the effect of A-ch at muscarinic receptors in gut

INDICATIONS

- As an anti emetic – in nausea, vomitting

post operative vomitting

drug/disease induced vomitting

radiation sickness

morning/ motion sickness

- Gastritis

- Reflux oesophagitis

- Gastroenterology

CONTRAINDICATIONS

- Gastro intestinal perforation/ obstruction

- Epilepsy

- Parkinsonism

- Breast cancer

TRADE NAMES : Reglan, Perinorm, Metaclop, Emenil, Vominil

DOSAGE : oral – 5-10 mg TDS

INJ. – 2 ml TDS

ADVERSE EFFECTS

- Dizziness

- Diarrhoea

- Trismus,

- Tremors

- Gynaecomastia,

- Galactorrhoea

PHENARAMINE MALEATE INTRODUCTION

-It is an alkylamine derivative

- Antihistaminic

- Anti cholinergic property

- Anti muscarinic property

- Central sedative property

INDICATIONS

- In allergies – urticaria

itching

angioedema

dermatitis

- Common cold

- Motion sickness

- Insect bite

- To decrease the BP

CONTRAINDICATIONS

-Hypersensitivity

-Acute porphyria

TRADE NAME : Avil, Avil Retard

DOSAGE : Children-- syrup ------- 1-3 yrs : 2.5 ml TDS

3-12 yrs: 5 ml TDS

Inj ------- 0.6 – 2 ml i.m OD/BD

Adults -- oral ---- 25 – 50 mg TDS

inj ---- 1.2 ml i.m TDS

ADVERSE EFFECTS

- Abuse potential

- Dry mouth

- Blurred vision

- Constipation

- Retention of urine

HYDROCORTISONEINTRODUCTION

- It is a glucocorticoid ( corticosteroid)

- It causes adreno pituitary axis suppression

- They maintain fluid electrolyte balance

- They maintain functional status of skeletal, muscles and nervous system

INDICATIONS

- Acute allergic reactions

- Anaphylactic shock

- Status asthmaticus

- Addison’s disease

- Rheumatoid arthritis

- Pruritis

- Tubercular meningitis

- Infective eczema

CONTRAINDICATIONS

- Neonates , infants

- Local/systemic infections

- Herpetic/fungal keratitis

- Cataract

TRADE NAMES : Corts, Lycortin, Primacort, Lutisoft cream, Neosporin – H

DOSAGES : Anaphylaxis – 100-150 mg/sec i.m 6 hourly

Status asthmaticus – 100-200 mg i.v 6 hourly

ADVERSE EFFECTS

- Hyperglycaemia

- Hyperkalemia

- Delayed wound healing

- Water and sodium retention

- Osteoporosis

- Calcium deposition

DEXAMETHASONE INTRODUCTION

- Corticosteroid derivative

- Long acting, very potent, highly selective glucocorticoid

- It causes marked pituitary adrenal suppression

- Anti-inflammatory and anti-allergic properties

INDICATIONS

- Allergic conditions

- Overwhelming infection

- Inflammation in eye disorder

- Shock due to trauma

- Rheumatoid arthritis

- Adjuvant anti emetic

- Adrenal crisis

CONTRAINIDICATIONS

-Diabetes mellitus

- Congestive heart failure

- Renal failure

- Tuberculosis

- Pyschosis

- Osteoporosis

TRADE NAME : Dexona, Dexavin, Decadan

DOSAGES : Children - 0.1 – 0.5 mg/kg/fay

Adults - 4-20 mg/day s.c/i.m/i.v

ADVERSE EFFECTS

- Hyperglycaemia, glycosuria

- Delayed wound healing

- Osteoporosis

- Cushing syndrome

DIAZEPAM INTRODUCTION

- Prototype of benzodiazepine

- Sedative hypnotic action

- Skeletal muscle relaxant

- Anti convulsant actiond

- Potentiates the neural GABA mediated inhibition in CNS

INDICATIONS

- Anxiety, tension

- Psychosomatic and behaviour disturbances

- Status epilepticus

- Tetanus

-Dysmenorrhoea

- Termination of prolongd seizure

- Local anaesthetic seizure

CONTRAINDICATIONS

- Hypersensitivity to benzodiazepines

- Acute narrow angle glaucoma

- Myasthenia gravis

TRADE NAMES : Calmpose, Calmod, Placidox

DOSAGES : Oral - 5-20 mg/day i.m in divided doses

inj – 10mg/2ml i.v

ADVERSE EFFECTS

- Respiratory depression

- GIT disturbance

- Drug dependance and abuse

FORTWIN – PENTAZOCINE INTRODUCTION

- Opioid analgesic

- Morphine like action

- It has agonist – antagonist type action that is weak antagonist and

marked agonist actions

INDICATIONS

- Chronic , recurrent, moderate to severe pain which is

assosciated with - - - surgery

trauma

fractures

labour pains

burns

cancer

CONTRAINDICATIONS

- Children below 12 years

- Hypertensives

- Ischaemia

- Myocardial infarction

TRADE NAMES : Fortwin, Fortagesic, Pentazocin, Pentawin

DOSAGES : 30 – 60 mg / ml i.v 3-4 hourly

ADVERSE EFFECTS

- Nausea, vomitting

- Euphoria

- Respiratory depression

- Hypertension, tachycardia, palpitation

- Withdrawl syndrome (rarely)

FUROSEMIDE INTRODUCTION

- It is a diuretic

- It causes loss of Nacl, Ca, K, Mg, PO 4, Na, water loss

- It causes pooling of blood in peripheral deep veins

- This effect occurs before the diversion and is important for the treatment of

left ventricular failure and pulmonary edema

INDICATIONS

- Oedema in congestive heart failure, hepatic disease,

renal disease and pulmonary oedema

- Hypertension

- To treat hypercalcaemia

- To treat drug overdose ------ by inducing forced diuresis and

facilitate rapid elimination of drug

CONTRAINDICATIONS

- Hypovolaemia

- Hypotonia

- Hepatic coma

- Renal failure with anuria and potassium defenciency

TRADE NAMES : Lasix, Frusenex, Salinex

DOSAGES : Children : 20 – 40 mg / day

Adults : Oral -- 40 – 100 mg

Inj -- 20 mg / 2 ml inj

ADVERSE EFFECTS

- Fluid and electrolyte imbalance

- Visual impairment

- Hearing impairment, deafness

- Muscle cramps

- Paraesthesia

PANCURONIUM BROMIDE INTRODUCTION

- Long acting, non depolarizing, peripherally acting

skeletal muscle relaxant

- Competitive antagonist of acetyl choline at neuro muscular junction

INDICATIONS

- Long acting skeletal muscle relaxant in surgical anaesthesia

- Assisted ventilation

CONTRAINDICATIONS

- Hypersensitivity

- Inadequate general aneasthesia

- Depressed ventilation

TRADE NAMES : Pavulon, Fancuron

DOSAGES : 2 mg/ ml i.v

ADVERSE EFFECTS

- Hypotension

- Bronchospasm

- Reduction in GI motility

- Wheel and flare reactions at site of injection

STYPTOCHROME INTRODUCTION

- It is a haemostatic agent

- It is a preparation of adrenochrome mono semi carbazone

- It exerts haemostatic action by reducing capillary fragility

- It prevents microvessel bleeding

INDICATIONS

- Epistaxis

- Retinal haemorrhage

- Secondary haemorrhage from wounds

- Haematuria

- Menorrhagia

CONTRAINDICATIONS

- Hypersensitivity

TRADE NAMES : Styptochrome, Cadisper – c, Styptocid

DOSAGES : Pre operatively 2-6 ml at suitable intervals

Postoperatively 1-2 ml every 2 hours

ETHAMSYLATE INTODUCTION

- It is a haemostatic agent

- It decreases capillary bleeding when platelets are adequate

- It inhibits PGI 2 production

- It corrects abnormal platelet function

INDICATIONS

- Epistaxis

- After tooth extraction

- Hematuria

- Malena

- After abortion

- Menorrhagia

- Post surgical conditions

CONTRAINDICATIONS

- Hypersensitivity

- Porphyria

- History of thrombocytopenia

purpura

haemophillia

TRADE NAMES : Ethamsyl, Hemsyl, Stat

DOSAGES : Oral -- 500 mg tab post operatively

inj -- pre operatively - - 1-2 ampules 1 hour before surgery

postoperatively - - 1-2 ampules 4 to 6 hourly

ADVERSE EFFECTS

- Nausea , headache

- Skin rashes

- Fall in BP after i.v injection

KETOROLAC INTRODUCTION

- It is a non steroidal anti inflammatory drug (NSAID)

- It is a pyrrolo-pyrrole derivative of non selective cox inhibitor (conventional NSAID)

- It is a potent analgesic, antipyretic, and anti inflammatory agent

- It relieves pain by peripheral mechanism

INDICATIONS

- Management of acute pain

- Post operative and acute musculoskeletal pain

- Renal colic

- Migraine

- Pain due to bony metastasis

- Post operative --inflammation

itching

allergy

CONTRAINDICATIONS

- Hypersensitivity

- After ocular surgery

- Peptic ulcer

-Coagulation disorder

TRADE NAMES : Ketorol, Ketotifen, Ketanov, Cadolac

DOSAGES : Oral - - 20 – 40 mg/day

Inj - - 4 – 6 ml i.m

ADVERSE EFFECTS

- Gastric disturbances

- Ocular irritation

- Wound healing abnormalities

- Superficial keratitis

AMINOPHYLLINE INTRODUCTION

- It is a bronchodilator

- Stable mixture of theophylline and ethylene di amine

- Directly relaxes smooth muscles of bronchi and lungs

- Stimulates CNS

- induces diuresis

- Increases gastric acid secretion

INDICATIONS

- Reversible airway obstruction

- Severe acute asthma

CONTRAINDICATIONS

- Hypersensitivity

- Hypertension

- Peptic ulcer

TRADE NAMES : Aminophylline, Deriphylline, Minophyl

DOSAGES : Oral - - 200-300 mg 3-4 times a day

Inj - - 200-500 mg slowly over 20 minutes

ADVERSE EFFECTS

- Tachycardia

- GI disturbance

- Convulsions

- Severe hyperventilation

SUCCINYL CHOLINE INTRODUCTION

- It is an ultra short actiong ,peripherally acting , neuro muscular blocking

skeletal muscles relaxant

INDICATIONS

- During General Anaesthesia

- During seizures

- Respiratory arrest during tracheal intubation

CONTRAINDICATION

- Glaucoma

- Myasthenia gravis

- In case of burns

- History of malignant hyperthermia

TRADE NAMES : Scoline, Scolax, Succinyl chloride, Succin inj

DOSAGES : 20- 100 mg

ADVERSE EFFECTS

- Hypertension

- Hyperkalemia

- Hyperthermia

- Raised intra cranial pressure

- Muscle pain

- Respiratory depression

DEXTROSE INTRODUCTION

- It is a hyperglycemic agent

- It rapidly elevates the blood glucose level by mobilizing hepatic

glycogen and converting it to glucose

INDICATIONS

- Severe hypoglycaemia

- Diagnostic tool in unconsciousness and

seizures of unknown origin

- Cardiogenic shock (rarely)

CONTRAINDICATIONS

- Chronic hypoglycaemia

- Hyperglycaemia

- Starvation states

TRADE NAMES : Glucagon

DOSAGES : 1md dry powder + 1 ml diluent

(50 ml bottle for emergency kit – 50 % dextrose)

ADVERSE EFFECTS

- Nausea, vomitting

- Allergic reaction

- Tissue necrosis if there is infiltration

SODIUM BICARBONATE INTRODUCTION

- It is an antacid n used to correct acidosis assosciated with hypoxia

cardiorespiratory arrest

metabolic acidosis

- Adequate ventilation is necessary whenever sodium bicarbonate is given because

carbon di oxide is produced in this procedure

INDICATIONS

- Reversal of metabolic acidosis occurring during anaerobic metabolism in

cardiopulmonary arrest

- Calcium and vitamin D defeciency states

- Pregnancy and lactation

- Bladder washes\

- Auricular lavage

- Bronchial lavage

CONTRAINDICATIONS

- In alkalosis

- Respiratory depression

- Hypocalcaemia

- Sodium overload

TRADE NAMES : Sodium bicarbonate

DOSAGES : 90 – 180 mEq / lit

ADVERSE EFFECTS

- Metabolic alkalosis with impairment of release of oxygen from Hb

- Sodium and water overload

- Local pain

- Venous irritation

CALCIUM GLUCONATE INTRODUCTION

- Essential for cardiac function

muscle contraction

nerve activity and

blood coagulation

- To maintain standard integrity of all membranes

- It causes neuro transmitter release

DEFENCIENCY SIGNS AND SYMPTOMS :

- Osteoporosis

- Pathologic fracture

- Brittle nails and hair

INDICATIONS ORAL INJECTIONS

Mild hypocalcaemia Severe hypocalcaemia

Growing children Hypoparathyroidism

Pregnancy Hyperkalemia

Lactation Cardiac arrest

Post menopausal women Every fourth bottle of

Rickets blood transfusion

Osteomalacia

CONTRAINDICATIONS

- Renal calculi

- Hypophosphataemia

- Hypercalcemia

- Hypoparathyroidism

TRADE NAMES : Calciium sandoz, Calcid, Calcibom

DOSAGES : Oral -- 1 gram

Inj -- 10 % inj

ADVERSE EFFECTS

- Constipation

- Abdominal discomfort

- Bloating

- Dyspepsia

-Excess gas

Common drug interactions in oral surgical practice

DrugDrug Interacting DrugInteracting Drug Drug InteractionDrug Interaction

1)Antihistamin1)Antihistaminee

CNS depressantsCNS depressants Increased drowsiness and sedationIncreased drowsiness and sedation

2)2) Salicylates Salicylates 1)1) Anticoagulants Anticoagulants

2)2) AntacidsAntacids

3)3) CorticosteroidCorticosteroid

4)4) MethotrexateMethotrexate

5)5) Oral Oral hypoglycaemicshypoglycaemics

6)6) Phenytoin Phenytoin

Increased risk of bleeding Increased risk of bleeding

Premature release of aspirin Premature release of aspirin

Increased risk of gastroitestinal Increased risk of gastroitestinal bleedingbleeding

Increased risk of methotrexate Increased risk of methotrexate toxicitytoxicity

Potentiates hypoglycaemic drugs Potentiates hypoglycaemic drugs effect effect

Increased effect of antiepileptics Increased effect of antiepileptics

3) Atropine3) Atropine 1) Alcohol1) Alcohol Impaired motor performance and Impaired motor performance and increased drowsiness.increased drowsiness.

4)4)Carbamazepine Carbamazepine

5)5)Corticosteroids Corticosteroids

1)1) AlcoholAlcohol

2)2) Barbiturates, Barbiturates,

doxy cycline doxy cycline

oral oral hypoglycemics hypoglycemics steroidssteroids

3)3) Erythromycin Erythromycin

1)1) Anti diabetic Anti diabetic drugsdrugs

2)2) Anti Anti hypertensives hypertensives

3)3) Oral Oral cotraceptives cotraceptives

Depressed CNSDepressed CNS

Depressed CNSDepressed CNS

Retarded effect of drugRetarded effect of drug

Increased carbamazepine isoniazid Increased carbamazepine isoniazid plasma level resulting in sedation plasma level resulting in sedation

Corticosteroids may exacerbate Corticosteroids may exacerbate diabetic state by hypoglycemic action diabetic state by hypoglycemic action

Antagonism due to fluid retentionAntagonism due to fluid retention

Increased anti-inflammatory response Increased anti-inflammatory response to topical steroids to topical steroids

6) 6) CotrimoxazoleCotrimoxazole

1)1) Diuretics Diuretics

2)2) Anti coagulants, Anti coagulants, anti epileptics, anti epileptics, oral oral hypoglycemics hypoglycemics

Increased risk of thrombocytopenia in Increased risk of thrombocytopenia in elderly elderly

Potentiate action of these agents Potentiate action of these agents

7)Diazepam7)Diazepam CNS depressants CNS depressants Intensified sedative effects Intensified sedative effects

8) Doxy cycline8) Doxy cycline 1) Penicillin1) Penicillin

2) Barbiturates, 2) Barbiturates, antiepileptics antiepileptics

Reduced effect of penicillinReduced effect of penicillin

Possiblility of reduced plasma Possiblility of reduced plasma concentration of Doxy cycline. concentration of Doxy cycline.

9) Metronidazole 9) Metronidazole 1) Alcohol 1) Alcohol

2) Antiepileptics 2) Antiepileptics

3) Anticoagulants 3) Anticoagulants

4) Barbiturates4) Barbiturates

Antagonism, therefore alcohol should Antagonism, therefore alcohol should be avoided be avoided

Incereased risk of toxicity of phenytoinIncereased risk of toxicity of phenytoin

Potentiated anticoagulant effectPotentiated anticoagulant effect

Reduced plasma level of Reduced plasma level of metronidazole metronidazole

10)Penicillin10)Penicillin oral oral Contraceptives Contraceptives

Increased bleeding, possibly with Increased bleeding, possibly with contraceptive failure contraceptive failure

11)Tetracyclines11)Tetracyclines Oral Oral contraceptives contraceptives

Oral hypoglycemicOral hypoglycemic

MethotrexateMethotrexate

Increased bleeding due to Increased bleeding due to contraceptive faliure contraceptive faliure

Increased hypoglycemic effectIncreased hypoglycemic effect

Incerased methotrexate toxicityIncerased methotrexate toxicity

References :

1. Essentials of medical pharmacology (By K.D.Tripathi).

2. A text book of pharmacology (Satoskar).3. A text book of Oral and Maxillofacial surgery (By B. Srinivasan). 4. Contemporary Oran and Maxillofacial Surgery

(By Peterson).