Anticholinergics

Question 1

What is the dose of atropine when used with edrophonium as a reversal

Answer 1

0.014 mg/mg edrophonium

Question 2

Dose of atropine when used for bradycardia

Answer 2

0.2-0.4 mg

Question 3

Indications for atropine

Answer 3

• Reversal with Enlon
• Brady Arrhythmias
• Vagal stimulation ( Ex. by occulocardia reflex or peritoneal stimulation).

Question 4

In what patients should you cautiously use atropine

Answer 4

• Narrow-angle glaucoma –> (atropine = sympathetic stimulation which dilates pupils and decreases outflow of intraocular aqueous humor, which increases IOP)
• crosses the placenta to increase FHR and decrease beat-to-beat variability in baby

Question 5

MOA of atropine

Answer 5

• Competitive acetylcholine antagonist @ central and peripheral receptors
• antimuscarinic
• naturally occurring alkaloid
• Tertiary amine

Question 6

CV effects of atropine

Answer 6

Increased HR

Question 7

Would glyco or atropine be a better choice to increase HR in eye surgery, pneumoperitoneum for lap cases, pull on peritoneum or cervix?

Answer 7

Atropine because it is better for increasing HR from vagal stimulation

Question 8

Onset and DOA of atropine

Answer 8

Onset = < 1 min

DOA = 30 min (IV)

2-4 hours (IM)

Question 9

Is atropine a tertiary or quarternary amine

Answer 9

Tertiary amine

Question 10

Other name for glycopyrolate

Answer 10

Robinul

Question 11

Dose of robinul when used as a reversal with neostigmine

Answer 11

0.2 mg/mg Neo

Question 12

Indications for robinul

Answer 12

Reversal agent, antisialoguge, bradycardia

Question 13

MOA & CV effects of glycopyrolate

Answer 13

MOA:

• competitive ACh antagonist
• synthetic antimuscarinic

CV:

• increase HR (not as extreme as atropine)

Question 14

Why might you give robinul in preop

Answer 14

In situation you want pt “dry” and need to increase HR

Question 15

Onset and DOA of Glycopyrollate

Answer 15

Onset:
- 1 min IV
- 15-30 min IM

DOA:
- vagal blocking = 2-3 hours
- antisialogous = up to 7 hours

Question 16

T or F: glycopyrollate readily crosses BBB and placenta

Answer 16

F — quarternary ammonium does not cross easily

Question 17

Indication for scopolamine

Answer 17

• decrease secretions
• PONV
• motion sickness/vertigo
• unstable trauma patient
• dilate pupils and cycloplegia

Question 18

Contraindications for scopalamine

Answer 18

Can cause toxic psychosis in elderly

• effects from restlessness to agitation

Question 19

MOA of scopalamine

Answer 19

Competitive antagonist of ACh at muscarinic receptors

Antagonizes histamine and serotonin

tertiary amine, naturally occurring Alkaloid

Question 20

Clinical considerations for scopalamine

Answer 20

• causes a lot of amnesia — good for trauma pts, women who get N/V
• decrease secretions/motion sickness
• don’t touch eyes after handling this med (can dilate pupils for 12 hours).
• remove after 24 hours and wash hands!

Question 21

T or F: scopolamine crosses BBB

Answer 21

T - tertiary compound, naturally occurring alkaloid

Question 22

Glycopyrrolate uses/effects:

Answer 22

Used in combo with Neostigmine for reversal; antisialogogue (xerostomia); increases HR
Causes NO CNS symptoms or mydriasis: quartenary ammonium

Question 23

Glycopyrrolate drug class and MOA:

Answer 23

Synthetic antimuscarinic; competitive ACh antagonist

Question 24

Glycopyrrolate (___)

Answer 24

___ (Robinul)

Question 25

Central Anticholinergic Syndrome treatment and dose:

Answer 25

Treat with Physostigmine: tertiary amine that crosses BBB Dose: 1-2 mg IV and may need to be repeated every 1-2 hrs (physostigmine is metabolized rapidly)

Question 26

Central Anticholinergic Syndrome signs:

Answer 26

- anxiety - disoriented - hyperactive - sedation - seizure - mydriasis - increased HR - atropine flush - dry/flushed skin - atropine fever Can be mistaken for delayed recovery from anesthesia

Question 27

Scopolamine dose (conc.): duration:

Answer 27

**Dose:** - 0.3-0.5 mg IM or IV - 1.5 mg transdermal patch **Concentration:** - 0.4 mg/cc **DOA:** 24-48 hrs

Question 28

Glycopyrrolate dose: onset: DOA:

Answer 28

0.2 mg per 1 mg Neostigmine onset: about 1 min IV 15-30 min IM DOA: 2-4 hrs

Question 29

Scopolamine is a (tertiary amine/quaternary ammonium)

Answer 29

tertiary amine

Question 30

Glycopyrrolate is a (tertiary amine/quaternary ammonium).

Answer 30

quaternary ammonium

Question 31

Atropine is a (tertiary amine/quaternary ammonium).

Answer 31

tertiary amine

Question 32

Atropine dose: onset: duration:

Answer 32

0.014 mg/mg of edrophonium OR 0.2-0.4 mg for vagal stimulation onset: 1 min duration: up to 30 mins

Question 33

Primary reason for giving muscarinic antagonist agents?

Answer 33

Used to antagonize the muscarinic effects of anticholinesterases used to reverse NDMBs (anticholinesterases cause increase in ACh, which stimulates the parasympathetic pathway and causes SLUDGE)

Question 34

General effects of all muscarinic antagonists:

Answer 34

Opposite of SLUDGE: inhibits salivation, lacrimation reduces gastric secretions and motility causes bronchodilator increases HR

Question 35

Muscarinic antagonists' MOA and primary effect:

Answer 35

Competitive inhibitors of ACh at **parasympathetic** muscarinic receptors --> primary effect is to increase HR