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121. ASCIA Guidelines: Chronic Spontaneous Urticaria (CSU)

that adherence to medications (for example, regular compared with on-demand antihistamines) has any influence on the natural history of CSU but it has been shown to result in improved QoL (Grob, Auquier, Dreyfus & Ortonne, 2009). Antihistamines First generation (sedating) H1 antihistamines First generation sedating antihistamines (diphenhydramine, hydroxyzine, promethazine, chlorpheniramine, dexchlorpheniramine) have been shown to be effective in patients with CSU There is no evidence that their efficacy

2019 Australasian Society of Clinical Immunology and Allergy

126. How well do you know your anticholinergic (antimuscarinic) drugs?

Prescribing Principles • Before prescribing, consider a patient’s total anticholinergic burden by reviewing all drugs. Inform patients about anticholinergic effects of over the counter drugs (e.g. “Gravol” or “sleep aids” containing diphenhydramine). • Alert patients and families that using drugs that block cholinergic neurotransmission in the brain can increase the risk of cognitive impairment and may be risky long-term. • Prescribe anticholinergics only for a clear indication. Document the purpose

2018 Therapeutics Letter

127. CRACKCast E194 – Pain Management

of anaphylaxis to local anesthetic? Very rare. Often the offending agent is the preservative used. In this case, you could substitute an agent from a different class – the preservatives don’t typically cross- react. However – if the patient has a true anaphylactic allergy to all ‘caine anesthetics – you can locally inject diphenhydramine (dilute 1 mL of a 50mg/mL ampoule with 5 or 10 mL of saline to make a 1% – 0.5% solution) [2] Why should you avoid use of the following agents: Tramadol Tramadol is a dirty

2018 CandiEM

128. CRACKCast E164 – Plants, Mushrooms, and Herbal Medications

oxalate crystals Ingestions can result in vomiting, mucosal irritation, ulceration, and edema Look for airway compromise in severe ingestions Dermal exposures may lead to contact dermatitis Treatment = supportive, including maintenance of a patent airway. Corticosteroids and antihistamines = adjunctive therapies diphenhydramine (25 to 50 mg intravenous push [IVP]) and dexamethasone (4 to 8 mg IVP) Umbrella Tree (Schefflera arboricola) Dumb cane (Dieffenbachia) Capsicum annuum aka all those peppers you

2018 CandiEM

129. CRACKCast E179 – Drug Therapy in Pregnancy

succinate Ginger Diphenhydramine Dimenhydrinate Metoclopramide Prochlorperazine Ondansetron DO NOT use Codeine Ergotamine This post was uploaded and copyedited by Riley Golby ( ) (Visited 888 times, 1 visits today) Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine. His interests are in endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's

2018 CandiEM

131. CRACKCast E177 – Acute Complications of Pregnancy

for treatment of nausea and vomiting of pregnancy (NVP) – great flowchart from Uptodate Safe PO options: Red = options for hyperemesis gravidarum Avoiding dietary triggers Ginger 250 mg po QID Pyridoxine (vitamin B6) 10-25 mg PO QID Diclectin: Doxylamine 10 mg and pyridoxine 10 mg Any of the below listed IV agents; if the patient can tolerate PO this would be a safe approach: (most “safe” drug to “least” safe) Dimenhydrinate / diphenhydramine Metoclopramide Ondansetron Great recent 2017 Cochrane review (...) conclusion – Uptodate. Citing PMID (dopamine antagonist) Metoclopramide, promethazine, prochloroperazine (antihistamine H1 antagonists) Dimenhydrinate, meclizine or diphenhydramine [better safety profile for mother and unborn that most other drugs] Glucocorticoids Bottom line = no drug is 100% safe; no one drug is the best; each has its own safety and side effect profile, but they are all widely used and supported 21) Describe the diagnosis and management of PE and DVT in pregnancy Both are tough

2018 CandiEM

133. Guidelines for sedation and anesthesia in GI endoscopy

in patients at increased risk of developing QT interval prolongation (eg, patients receiving other medications known to increase the QT interval; patients with a history of congestive heart failure, bradycardia, diuretic use, cardiac hypertrophy, alcohol abuse, hypokalemia, hypomagnesemia; aged >65 years) because of the risk of ventricular tachyarrhthmias. 47,48 In addition, the use of diphenhydramine has been shown to improve sedation and decrease pain in patients undergoing colonoscopy (...) thatall patients undergoing endoscopic procedures be evaluated to assess their risk of sedation related to pre-existing medical conditions.4444 2. We recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events.4444 3. We suggest using an appropriate adjunctive agent (eg, diphenhydramine, promethazine, or droperidol

2018 American Society for Gastrointestinal Endoscopy

134. CRACKCast Episode 148 – Acetaminophen

. These observations have led some authors to suggest that a higher dose of N-acetylcysteine may be required for large overdoses, and a computerized simulation of overdose supports this concept. However, there are no controlled studies demonstrating that increasing the dose of acetylcysteine prevents liver injury following massive overdose.” [3] How does co-ingestion of diphenhydramine (Benadryl) impact Tylenol OD? As discussed multiple times, co-ingestion with anticholinergics will impact gut motility, and can (...) impact both your absorption times (i.e. interfering with nomogram interpretation) and may be associated with ongoing hepatocellular toxicity despite NAC 20hr IV protocol: “There are reports of adult patients with massive acetaminophen ingestion (ingestion >30 g, or serum concentration >500 mg/L [3300 μmol/L]) who develop liver injury despite early administration of N-acetylcysteine. Several of these cases involved coingestion of diphenhydramine and the patients had elevated acetaminophen

2018 CandiEM

135. CRACKCast E147 – General Approach to the Poisoned Patient

Sustained-release preparations (e.g., CCB’s, BB’s, Li) Enteric-coated preparations (e.g., ASA) MAOI’s Drug packet ingestion Oral Hypoglycemic Agents Cyanogenic Glycosides Warfarin Wise Cracks: [1] List / Mnemonic Madness: Toxicologic differential diagnosis for: Wide complex QRS (drugs that block sodium channels) : TCA’s Type 1a and 1c antidysrhythmics Cocaine Diphenhydramine Hypoglycemia : Oral hypoglycemic agents Beta blockers (especially in peds) Isoniazid (INH) Salicylates Sulfonylureas Insulin

2018 CandiEM

136. CRACKCast Episode 150 – Anticholinergics

” Hyperthermia: “Hot as Hades” Urinary retention: “Full as a flask” Decreased bowel sounds/ileus Tachycardia See Figure 145.1 In Rosen’s (9th) [2] List 10 anticholinergic meds In general the list you’ll see is: Plants Jimson weed belladonna alkaloids Atropine Scopolamine Antihistamines (H1 blockers) Dimenhydrinate Diphenhydramine Antiparkinson agents Benztropine (Cogentin) Procyclidine Tricyclic antidepressants Cyclobenzaprine Amitriptyline Let’s break this down into common antimuscarinic and antinicotinic (...) drugs Antimuscarinic agents Atropine Benztropine (Cogentin) Dimenhydrinate (Gravol, Dramamine) Diphenhydramine (Benadryl, Nytol, Advil PM, etc.) Doxylamine (Diclectin, Restavit, Unisom) Glycopyrrolate (Robinul) Ipratropium (Atrovent) Oxybutynin (Ditropan, Driptane, Lyrinel XL) Tiotropium (Spiriva) Tricyclic antidepressants (28 compounds with numerous trade names) Scopolamine Tropicamide Antinicotinic agents Bupropion (Zyban, Wellbutrin) – Ganglion blocker Dextromethorphan – Cough suppressant

2018 CandiEM

137. CRACKCast E151 – Antidepressants

and second generation eg chlorpromazine, ) Anticonvulsants (eg dilantin, Carbamazepine) Anti-Parkinson’s agent (eg Amantadine ie dopamine agonist) Cocaine Antihistamine agents (eg Diphenhydramine) Dextropropoxyphene (opioid brand name Darvon-N in Canada, now recalled) Wisecracks [1] What are the indications for Bicarb in TCA toxicity? QRS > 100 (if different from baseline) Hypotension Dysrhythmia Seizures Acidosis When do you switch to Hypertonic? pH > 7.55 Failure of QRS to respond to NaHCO3 [2] List 3 (...) of abuse (cocaine and amphetamine derivatives) anticholinergic (or antimuscarinic) toxicity (diphenhydramine, cyclic antidepressants, anti-Parkinson drugs, and jimson weed) methylxanthine toxicity (eg, theophylline and caffeine) acute withdrawal states (eg, ethanol and benzodiazepines) neuroleptic malignant syndrome (NMS) serotonin syndrome environmental hyperthermia or heat stroke meningitis and encephalitis Pheochromocytoma carcinoid syndrome thyroid storm hypertensive emergency This episode

2018 CandiEM

138. CRACKCast E165 – Sedative Hypnotics

in Perspective Big headings for today: Barbiturates Benzodiazepines Special sedatives / OTC sleep aids Chloral hydrate Gamma-hydroxybutyrate (GHB) We’ll cover most of these in the core questions, but let’s quickly mention the sleep aids, because we won’t cover them specifically later on. Over-the-counter (OTC) sleep aids currently available in the United States contain either diphenhydramine or doxylamine. Many preparations also contain acetaminophen or aspirin, added to achieve nighttime pain relief. (check (...) those ASA and acetaminophen levels!!) Diphenhydramine and doxylamine are antihistamines that also have hypnotic, antimuscarinic, and weak local anesthetic properties. They act as competitive antagonists of H1 histamine receptors and cause sedation by inhibiting the actions of acetylcholine on muscarinic receptors in the CNS. Other special sedatives: Flunitrazepam (Rohypnol) – Not sold in the USA, but purchased online and commonly associated as a “date” rape drug the Zzzzs Zolpidem (Ambien), zaleplon

2018 CandiEM

140. Acute Rhinosinusitis in Adults

Rhinitis) Chlorpheniramine (Chlor-Trimeton®) 4 mg every 4-6 hours or sustained release 8-12 mg every 12 hours gen $8-23 Clemastine (Tavist®) 1.34 mg every 12 hours gen $8 Diphenhydramine (Benadryl®) 25-50 mg every 6 hours gen $12 Less-sedating (2 nd generation) antihistamines (loratadine, fexofenadine, cetirizine) Steam, saline spray Guaifenesin (except possibly at high dose) * Cost=Maximum Allowable Cost (MAC) + $3 for generics on 30-day supply or less, Michigan Department of Community Health M.A.C

2018 University of Michigan Health System

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