Presentation is loading. Please wait.

Presentation is loading. Please wait.

Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital AHA Evidence Based Guidelines How to proceed with scant evidence.

Published byJocelyn Chase Modified over 9 years ago

Similar presentations

Presentation on theme: "Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital AHA Evidence Based Guidelines How to proceed with scant evidence."— Presentation transcript:

1 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital AHA Evidence Based Guidelines How to proceed with scant evidence

2 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Levels of Evidence 1

3 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Levels of Recommendation

4 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital AHA Guidelines  Cocaine-Induced Ventricular Dysrhythmias l Recommended Therapies, Ordered By Preference: –Sodium Bicarbonate (IIB), Lidocaine (IIB), Alpha Adrenergic Blockers (IIB) l Inappropriate Therapies: –Non-Selective Beta Blockers, Epinephrine (Both III)  Cocaine-Induced Acute Coronary Syndrome (ACS) l Recommended Therapies, Ordered by Preference: –Benzodiazepines (IIB), Nitrates (IIB), Alpha- Adrenergic Antagonists (IIB) l Inappropriate Therapies: –Non-Selective Beta-Blockers (III)

5 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital AHA Guidelines  Calcium Channel Blocker Poisoning or Overdose l Recommended Therapies, Ordered By Preference: –Pacemaker, Vasopressors, High-Dose If Necessary(IIB), Calcium (IIB)  Beta-Blocker Poisoning or Overdose l Recommended Therapies, Ordered By Preference: –Pacemaker, Vasopressors, High-Dose If Necessary (IIB), Glucagon (IIB)

6 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital AHA Guidelines  Tricyclic Antidepressant Poisonings l Recommended Therapies, Ordered By Preference: –Sodium Bicarbonate (IIB), Lidocaine l Inappropriate Therapies: –Procainamide (III)  Refractory Drug-Induced Shock l High-Dose Vasopressors (IIB), Circulatory Assist Devices (IIB), Vasopressin (Indeterminate)

7 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Opiate Poisoning: Ventilation before Naloxone? Dr Andrew Dawson Director Hunter Area Toxicology Service Newcastle, Australia

8 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Opiate Poisoning: Ventilation before Naloxone?  “Evidence supports the correction of respiratory failure with bag valve mask techniques followed by administration of naloxone in any patient suspected of opioid induced respiratory failure.”

9 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Are all clinical situations the same?  24 year male recreational heroin OD  75 year male IHD post operative narcosis  24 year old post heroin OD respiratory arrest being ventilated

10 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Naloxone & Ventilation Grid

11 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Naloxone: Efficacy  Animal –Good controlled studies  Clinical data –Anaesthetic l Good controlled studies –Clinical Toxicology l Case series –indirectly address the issues

12 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Naloxone: Risk  Incidence of possible ADR <1%  Seizure & cardiac arrest –Extremely rare –Probably catecholamine mediated  ? Pulmonary Oedema  Behavioural 7%

13 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Naloxone & Catecholamines  Increases catecholamine release –especially in the presence of hypercapnoea –The correction of of hypercapnoea reduces haemodynamic effects. l Mills CA (1988)  There is no clinical evidence to support hypercapnoea correction prior to administration of naloxone.

14 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Mills et al

15 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Mills et al

16 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Naloxone Dose  0.12 mg endpoint ETCO 2 < 6.5% Tigerstedt  Out of Hospital: Protocol Driven

17 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Respiratory Arrest/Depression  Detectable pulse & BP  >90% response to naloxone  IV=IM –Sporer et al  IV=SC –Wanger et al

18 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Opioids: Asystolic arrest  Prehospital physician & paramedic medical team survival (4/7) –all IV naloxone l Bertini G et al 1992.  Prehospital paramedic (0/16) –50% received naloxone IV l Sporer KA et al 1996

19 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Is Naloxone Neurotoxic?  Glutamate mediated neuroexcito-toxicity  Modulating effect of endorphines & morphine  Direct effects of Naloxone

20 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Excitatory amino acids, glutamate Increased intracellular calcium and sodium Protein kinases C, II Proteases Phosphatases Excitotoxicity Ca 2+ Phospholipases Xanthine oxidase Nitric oxide synthase (NO) Heme oxygenase (CO) Endonucleases

21 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Glutamate accumulation Astrocyte Presynaptic Postsynaptic Astrocyte

22 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital NMDA Sodium and Calcium NMDA or glutamate Glycine Poly- amine H+H+ Phencyclidine Zinc Magnesium SH NO-S

23 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital AMPA, Kainate Sodium or Calcium AMPA Kainic acid or glutamate 2,3-benzo- diazepines

24 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Drug modification  Decreased glutamate release –Adenosine derivatives, catecholamines –Sodium channel blockers l Phenytoin l Lamotrigine –Ca 2+ -channel blockers (L-type) l Nimodipine –Platelet activating factor antagonists

25 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Drug modification  Glutamate receptor antagonism –Glutamate binding site –2,3-benzodiazepine site l GYKI 52466, ? very high dose diazepam –Glycine binding site l Felbamate –Receptor associated ion channel l Magnesium, ketamine, memantine –Redox modulatory site l Nitroglycerine, nitroprusside

26 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Opioids: Ventilation before Naloxone  “Evidence supports efforts to correct respiratory acidosis and hypoxia followed by naloxone administration in patients suspected of opioid induced respiratory failure.”  Class IIb

27 Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Naloxone Dose  IMI: 0.8mg –If systolic BP >100 mmHg  IV: 0.4 mg –Cardiac arrest –If an IV line is in situ  Repeated & titrated against response  Rate of non-behavioural adverse reactions does not appear to be related to dose

Download ppt "Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital AHA Evidence Based Guidelines How to proceed with scant evidence."

Similar presentations

Education and Training Module for Ohio EMS Developed in the 1960s Opioid antagonist Emergent overdose treatment in the hospital and prehospital settings.

Education and Training Module for Ohio EMS Developed in the 1960s Opioid antagonist Emergent overdose treatment in the hospital and prehospital settings.
ACLS Medications.

ACLS Medications.
Which drug (other than Valium) may be used to terminate status epilepticus?

Which drug (other than Valium) may be used to terminate status epilepticus?
Joint Special Operations Medical Training Center INFUSION RATE CALCULATIONS.

Joint Special Operations Medical Training Center INFUSION RATE CALCULATIONS.
Opioids & Sedatives Toxicity

Opioids & Sedatives Toxicity
Synapses Figure 11.17.

Synapses Figure
Pharmacological Approaches to Neuropathic Pain. Differential Diagnosis Pain of dental origin Oral soft tissue pain Temporomandibular joint pain Myofascial.

Pharmacological Approaches to Neuropathic Pain. Differential Diagnosis Pain of dental origin Oral soft tissue pain Temporomandibular joint pain Myofascial.
Pediatric Prehospital Seizure Management: Evidence Based Guidelines and State of Care in CO Kathleen Adelgais, MD MPH Pediatric Emergency Medicine Children’s.

Pediatric Prehospital Seizure Management: Evidence Based Guidelines and State of Care in CO Kathleen Adelgais, MD MPH Pediatric Emergency Medicine Children’s.
ACLS ALGORITHMS.

ACLS ALGORITHMS.
OPIOIDS NIRALI PATEL (2009) Medical University of Sofia, Faculty of Medicine Department of Pharmacology and Toxicology.

OPIOIDS NIRALI PATEL (2009) Medical University of Sofia, Faculty of Medicine Department of Pharmacology and Toxicology.
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Relative toxicity of venlafaxine and serotonin specific reuptake inhibitors.

Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Relative toxicity of venlafaxine and serotonin specific reuptake inhibitors.
Cardiac Arrest Skills Station

Cardiac Arrest Skills Station
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Calcium channel blockers Professor Ian Whyte Hunter Area Toxicology Service.

Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Calcium channel blockers Professor Ian Whyte Hunter Area Toxicology Service.
Anesthesia for Drug Abusers Clinton Piper, MS3. - Narcotics - Barbs and Benzos - Hallucinogens - Amphetamines - Cocaine Anesthesia for Drug Abusers Nick.

Anesthesia for Drug Abusers Clinton Piper, MS3. - Narcotics - Barbs and Benzos - Hallucinogens - Amphetamines - Cocaine Anesthesia for Drug Abusers Nick.
Drug-Induced Seizures (in 15 minutes or Less) Robert S. Hoffman, MD Director, NYC Poison Center Associate Professor Emergency Medicine and Medicine NYU.

Drug-Induced Seizures (in 15 minutes or Less) Robert S. Hoffman, MD Director, NYC Poison Center Associate Professor Emergency Medicine and Medicine NYU.
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Calcium channel blockers Professor Ian Whyte Hunter Area Toxicology Service.

Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Calcium channel blockers Professor Ian Whyte Hunter Area Toxicology Service.
Strategy 2: Make the tissue more resilient to poor plumbing. Pros: -Likely a pharmacological treatment -Can be administered more quickly by 1 st response.

Strategy 2: Make the tissue more resilient to poor plumbing. Pros: -Likely a pharmacological treatment -Can be administered more quickly by 1 st response.
Respiratory & Medical Critical Care and Paramedic Levels.

Respiratory & Medical Critical Care and Paramedic Levels.
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Cardiac arrhythmia  Primary –quinidine–like drugs, sympathomimetic drugs, calcium.

Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Cardiac arrhythmia  Primary –quinidine–like drugs, sympathomimetic drugs, calcium.
MEDICATIONS. Medications Epinephrine Volume expanders Sodium bicarbonate Naloxone Dopamine.

MEDICATIONS. Medications Epinephrine Volume expanders Sodium bicarbonate Naloxone Dopamine.

Similar presentations

Ads by Google