Emergencies





5. Cardiac Emergency Drugs.--Besides some of the drugs already

mentioned (such as camphor hypodermically, nitroglycerin when

indicated, strophanthin hypodermically or intravenously, caffein and

strychnin), often ergot, suprarenal vasopressor principle, pituitary

vasopressor principle, atropin and morphin should be considered.



When there is low blood pressure, venous stasis, pulmonary

congestion, cyanosis and a laboring, failing heart, intramuscular

injections of ergot, with or without coincident venesection, may be

the most valuable method of combating the condition. Life has been

saved in this kind of sudden acute cardiac failure in valvular

disease. When venesection is not indicated in certain conditions of

low blood pressure and heart failure, ergot has saved life. It

causes contraction of the blood vessels and seems to tone the heart.

Incidentally it quiets the central nervous system. If the blood

pressure is much increased by it, the ergot should not be repeated,

as too much work should not be thrown on the heart muscle. Often,

however, it may be administered intramuscularly with advantage in

aseptic preparation as offered in ampules, at the rate of one ampule

every three hours for two or three times, and then once in six hours

for a few times, the future frequency depending on the indications.



Epinephrin and Pituitary Extract: The blood pressure-raising

substance of the suprarenals or of the pituitary gland (hypophysis

cerebri) has been much used in heart failure. These substances

certainly would not be indicated in high blood pressure; they are

indicated in low blood pressure. They have been given intravenously;

they are frequently given hypodermically. They often act rapidly

when a solution in proper dose is dropped on the tongue. The blood

pressure rise from epinephrin is quickly over; that from the

pituitary extract lasts longer. In large doses, or when it is too

frequently repeated, epinephrin depresses the respiration. Pituitary

extract acts as a diuretic. Sterilized solutions of both, put up in

ampules ready for hypodermic medication, are obtainable, the

strength offered generally being 1 part of the active principle to

10,000 of the solution. Hypodermic tablets of epinephrin may also be

obtained. Stronger solutions of 1 part to 1,000 may be dropped on

the tongue, or tablets may be dissolved on the tongue. The blood

pressure is temporarily raised and the heart stimulated by these

treatments, but epinephrin is not used so often for cardiac failure

as it was a short time ago.



The most satisfactory action, especially from the epinephrin, is

from small doses frequently repeated. Sometimes in serious

emergencies it has been found to be of value when given

intravenously in physiologic saline solution. The close, of course,

should be very small. In circulatory weakness in acute illness,

epinephrin has been given regularly, a few drops (perhaps the most

frequent dose is 5) of a 1: 1,000 solution, on the tongue, once in

six hours. Such a dosage may be of value, and certainly is better

than the administration of too much strychnin. Much larger or more

frequent doses are likely, as just stated, to depress the

respiration.



Besides the small amount of blood pressure-raising substance

secreted by the hypophysis cerebri. it has not been shown that any

other gland of the body furnishes vasopressor substance except the

suprarenals.



Atropin: When there is great cardiac weakness, atropin may be used

to advantage. The dose is from 1/200 to 1/150 grain hypodermically,

not repeated in many hours. It will whip up a flagging heart, more

or less increase the blood pressure, cause cerebral awakening, and

may often be of value. If there is any idiosyncrasy against atropin,

if the throat and mouth are made intensely dry, or if there is

serious flushing or cerebral excitement, the dose should not be

repeated.



Morphin: This would rarely be considered as an emergency drug in

cardiac weakness. A small dose of it, not more than one-eighth

grain, especially if combined with atropin, will often quiet and

brace a weak heart, especially when there is cardiac pain. Just

which drug or drugs should be used and just which are not indicated

can never be specifically outlined in a textbook, a lecture or a

paper. The decision can be made only at the bedside, and then

mistakes, many times unavoidable, are often made.



In all conditions of shock with cardiac failure, the blood vessels

of the abdomen and splauclinic system are dilated, and more or less

of the blood of the body is lost in these large veins, and the

peripheral and cerebral blood pressure fails. The advantage in such

a condition of firm abdominal bandages, and of raising the foot of

the bed or of raising the feet and legs, need only be mentioned to

be understood.



It is a pretty good working rule, in cardiac failure, not to do too

much. On the other hand, life is frequently saved by proper

treatment, and the physician repeatedly saves life as surely as does

the surgeon with his knife.





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