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PHARMACOLOGY EXAM NOTES - Quick Summary
1. AUTONOMIC DRUGS
1A. Adrenergic Agonists (Sympathomimetics)
| Drug | Receptor | Key Use |
|---|---|---|
| Epinephrine | α1,α2,β1,β2 | Anaphylaxis, cardiac arrest |
| Norepinephrine | α1,α2,β1 | Septic shock |
| Dopamine | multiple | Shock (dose-dependent) |
| Dobutamine | β1 | Cardiogenic shock (HF) |
| Phenylephrine | α1 | Nasal congestion, hypotension |
| Clonidine | α2 (central) | HTN |
| Albuterol | β2 | Asthma |
- Toxicity: Hypertensive crisis, arrhythmias
- Antidote: Phentolamine (HTN crisis), β-blocker for tachycardia
- NEVER give β-blocker alone in cocaine toxicity → unopposed α = disaster
1B. Adrenergic Antagonists (Sympatholytics)
- α1-blockers (Prazosin): HTN, BPH → side effect: first-dose hypotension
- β-blockers (Metoprolol, Propranolol): HTN, angina, HF, post-MI
- CI: Asthma, AV block, cocaine use (β-blocker alone)
- Overdose Rx: Glucagon (bypasses β-receptor) → High-dose Insulin → Atropine
1C. Cholinergic Agonists (Parasympathomimetics)
- Mnemonic - SLUDGE/DUMBELS: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis (+ Diarrhea, Miosis, Bradycardia)
- Key drugs: Bethanechol (urinary retention), Pilocarpine (glaucoma), Neostigmine (myasthenia gravis)
- Organophosphate Crisis: Atropine (high dose) + Pralidoxime (2-PAM) - give 2-PAM EARLY before "aging"
1D. Anticholinergics (Antimuscarinics)
- Mnemonic - 7 signs:
- HOT as a hare (hyperthermia)
- DRY as a bone (anhidrosis)
- RED as a beet (flushing)
- BLIND as a bat (mydriasis)
- MAD as a hatter (delirium)
- FULL as a flask (urinary retention)
- FAST as a fiddle (tachycardia)
- Antidote: Physostigmine (crosses BBB - for CNS effects)
2. ANTIPSYCHOTICS
| Class | Drugs | Mechanism |
|---|---|---|
| 1st Gen (Typical) | Haloperidol, Chlorpromazine | D2 blockade |
| 2nd Gen (Atypical) | Clozapine, Olanzapine, Quetiapine | D2 + 5-HT2A |
EPS Side Effects (Typicals >> Atypicals):
- Hours-days: Acute dystonia → Benztropine or Diphenhydramine IM
- Days: Akathisia (restlessness) → Propranolol or BZD
- Days-weeks: Parkinsonism
- Months-years: Tardive dyskinesia (irreversible) → Valbenazine/Deutetrabenazine
Clozapine = treatment-resistant schizophrenia BUT causes agranulocytosis (weekly WBC monitoring!)
NMS (Neuroleptic Malignant Syndrome):
- FEVER + Lead-pipe Rigidity + Autonomic instability + ↑CK
- Rx: STOP drug + Dantrolene + Bromocriptine
3. ANTIDEPRESSANTS
SSRIs (1st line for depression)
- SE: GI upset, sexual dysfunction (most common stop reason), hyponatremia (SIADH in elderly), bleeding risk
- Fluoxetine = longest half-life → least discontinuation syndrome
- Paroxetine = most weight gain
- CI: MAOIs (washout 2 weeks; Fluoxetine needs 5 weeks)
SNRIs
- Extra SE vs SSRIs: HTN (NE effect), urinary retention
- Duloxetine = diabetic neuropathy, fibromyalgia
TCAs (Amitriptyline, Imipramine)
- SE: Anticholinergic + Antihistamine + α1-blockade + QRS widening
- OD = 3 C's: Coma, Convulsions, Cardiotoxicity
- Rx: Sodium Bicarbonate IV (narrows QRS)
- AVOID Flumazenil (↑seizures), Physostigmine in TCA OD
MAOIs
- Best for atypical depression
- Tyramine crisis (cheese reaction): headache, hypertension → Phentolamine or Nitroprusside
- Washout = 14 days before/after switching to SSRIs
Other Key Antidepressants
| Drug | Use | Unique Side Effect |
|---|---|---|
| Bupropion | Depression + smoking + ADHD | Seizures (CI in bulimia/anorexia), NO sexual SE |
| Mirtazapine | Depression + insomnia | Sedation, weight gain |
| Trazodone | Insomnia (low dose) | Priapism (urologic emergency!) |
4. SEROTONIN SYNDROME
Caused by: Excess serotonin (SSRIs + MAOIs, Tramadol, Linezolid, Methylene blue, Dextromethorphan)
Classic Triad:
- Neuromuscular - CLONUS (most specific), hyperreflexia, tremor
- Autonomic - hyperthermia, diaphoresis, tachycardia
- Mental status - agitation, confusion
SS vs NMS:
| Feature | Serotonin Syndrome | NMS |
|---|---|---|
| Onset | Hours (rapid) | Days (slow) |
| Muscle | CLONUS | Lead-pipe rigidity |
| CK | Mildly elevated | VERY elevated |
| Cause | Serotonergic drugs | Antipsychotics |
| Treatment | Cyproheptadine | Dantrolene + Bromocriptine |
Rx: Stop drug + Cyproheptadine + BZDs + Cooling
5. LITHIUM
- Therapeutic: 0.6–1.2 mEq/L | Toxic: >1.5 | Severe: >2.0
- SE: Fine tremor (most common), polyuria (nephrogenic DI), hypothyroidism (20-40%), Ebstein anomaly (pregnancy)
- Things that ↑ Li levels: NSAIDs, Thiazides, ACEi, Dehydration
- Toxicity progression:
- 1.5-2.0: Coarse tremor, nausea
- 2.0-2.5: Confusion, ataxia
-
2.5: Seizures, coma, death
- Rx: IV Normal Saline → Hemodialysis if level >4.0 or severe
- AVOID forced diuresis (paradoxically increases reabsorption!)
6. ACE INHIBITORS & ARBs
- ACEi: Lisinopril, Enalapril (-pril) | ARBs: Losartan, Valsartan (-sartan)
- Use: HTN, HFrEF (MUST use), post-MI, diabetic nephropathy
- CI: Bilateral RAS, pregnancy (fetal renal agenesis), hyperkalemia, angioedema history
- ACEi unique SE: Dry cough (↑bradykinin) → switch to ARB
- Angioedema = airway emergency! Rx: Epi + Diphenhydramine + Icatibant
7. DIURETICS
| Type | Site | Key Use | Unique SE | Electrolytes |
|---|---|---|---|---|
| Thiazide | DCT | HTN, calcium stones | Hyperglycemia, gout | ↓K, ↓Na, ↑Ca |
| Loop (Furosemide) | Loop of Henle | Acute HF, hypercalcemia | Ototoxicity | ↓K, ↓Ca, ↓Mg |
| K-sparing (Spironolactone) | Collecting duct | Cirrhosis ascites, HF | Hyperkalemia, gynecomastia | ↑K |
| Acetazolamide | PCT | Glaucoma, altitude sickness | Paresthesias, kidney stones | ↓K, metabolic acidosis |
- Loop = only safe one in sulfa allergy: Ethacrynic acid
- K-sparing CI: Renal failure, ACEi + ARB combo (severe hyperkalemia!)
- Thiazide paradox: Treats nephrogenic DI (volume depletion → ↑proximal reabsorption)
8. SGLT2 INHIBITORS (Gliflozins)
- Drugs: Empagliflozin, Dapagliflozin, Canagliflozin
- Use: T2DM, HFrEF (mortality benefit even without diabetes!), CKD
- Key SE: Genital fungal infections (most common), UTIs, Euglycemic DKA (glucose may be NORMAL - easy to miss!), Fournier's gangrene (rare, surgical emergency)
- Stop 3 days before surgery to prevent euglycemic DKA
9. DIGOXIN
- Therapeutic: 0.5–0.9 ng/mL | Toxic: >2.0 ng/mL
- Mechanism: Inhibits Na/K-ATPase → ↑Ca → ↑contractility + ↑vagal tone (↓HR)
- Use: HFrEF (symptoms only, no mortality benefit), AFib rate control
- CI: WPW, 2nd/3rd degree AV block, hypokalemia (↑toxicity)
- Classic toxicity signs: Yellow-green halos (vision), PAT with block, bidirectional VT (pathognomonic)
- Things that ↑toxicity: ↓K, ↓Mg, ↑Ca, quinidine, amiodarone, verapamil
- Antidote: Digoxin Immune Fab (Digibind) - for K>5, level>10, life-threatening arrhythmias
- AVOID cardioversion in digoxin toxicity (can trigger VF)
10. CALCIUM CHANNEL BLOCKERS
| Class | Drugs | Main Effect |
|---|---|---|
| DHP | Amlodipine, Nifedipine | Vasodilation (↓BP) |
| Non-DHP | Verapamil, Diltiazem | ↓HR, ↓AV conduction |
- Non-DHP CI: Systolic HF, AV block, WPW + AF (→VF!)
- DHP SE: Peripheral edema (ankles), reflex tachycardia, flushing
- Non-DHP SE: Bradycardia, constipation (Verapamil classic!), AV block
- CCB OD Rx: Calcium IV + High-Dose Insulin (HIET) + Glucagon + Lipid emulsion
11. NITRATES
- Mechanism: NO → ↑cGMP → venodilation (↓preload) > arteriodilation (↓afterload)
- Use: Acute angina (SL NTG), acute HF, hypertensive emergency
- ABSOLUTE CI: PDE5 inhibitors (Sildenafil/Tadalafil) → severe hypotension!
- CI: RV infarction (dependent on preload!), HCM, severe aortic stenosis
- SE: Headache (most common), tolerance (need 10-12hr nitrate-free window)
- Methemoglobinemia: Chocolate-brown blood, normal PaO2 → Rx: Methylene Blue IV
- Nitroprusside cyanide toxicity → Rx: Hydroxycobalamin (preferred)
12. BETA BLOCKERS
- Cardioselective (β1): Metoprolol, Atenolol, Bisoprolol, Esmolol
- Non-selective: Propranolol, Nadolol, Timolol
- α+β: Labetalol, Carvedilol
- Use: HTN, angina, post-MI (mandatory!), HFrEF, AFib rate control, essential tremor, migraine prophylaxis
- CI: Asthma, AV block, cocaine, decompensated HF, NEVER stop abruptly (rebound angina/MI)
- Masks hypoglycemia (sweating preserved, tachycardia masked)
- OD Rx: Glucagon IV (1st line) → High-dose insulin → Calcium → Vasopressors
13. ANTIARRHYTHMICS (Vaughan Williams)
| Class | Mechanism | Drugs | Key Point |
|---|---|---|---|
| IA | Na block + K block (↑QT) | Quinidine, Procainamide | TdP risk; Procainamide → drug-induced lupus |
| IB | Na block + ↓QT | Lidocaine, Mexiletine | Post-MI VT; CNS toxicity first |
| IC | Strong Na block | Flecainide, Propafenone | CI in structural heart disease! (CAST trial) |
| II | β-blockade | Metoprolol, Esmolol | Rate control AF, post-MI |
| III | K block (↑QT) | Amiodarone, Sotalol | Amiodarone = most effective antiarrhythmic |
| IV | Ca block | Verapamil, Diltiazem | SVT termination, AF rate control |
| V | Misc | Adenosine, Mg, Digoxin | Adenosine = DOC for SVT (half-life <10 sec) |
Amiodarone is toxic to EVERY organ:
- Lung: Pulmonary fibrosis (most serious)
- Liver: Hepatotoxicity
- Thyroid: Hypo OR Hyperthyroidism
- Eyes: Corneal deposits (universal, usually benign)
- Skin: Blue-gray discoloration
- Half-life = 40-55 days (toxicity persists after stopping!)
- Increases levels of: Warfarin, Digoxin, Statins
Torsades de Pointes (TdP) = ↑QT arrhythmia:
- Rx: Magnesium Sulfate IV (drug of choice) + Overdrive pacing
QUICK ANTIDOTE CHEAT SHEET
| Drug/Toxidrome | Antidote |
|---|---|
| Organophosphate | Atropine + Pralidoxime (2-PAM) |
| Anticholinergic | Physostigmine |
| β-blocker OD | Glucagon → High-dose Insulin |
| CCB OD | Calcium + High-dose Insulin |
| Digoxin toxicity | Digibind (Digoxin Immune Fab) |
| TCA OD | Sodium Bicarbonate IV |
| Serotonin Syndrome | Cyproheptadine |
| NMS | Dantrolene + Bromocriptine |
| Lithium toxicity | Hemodialysis |
| Torsades de Pointes | Magnesium Sulfate IV |
| Methemoglobinemia | Methylene Blue IV |
| Nitroprusside (cyanide) | Hydroxycobalamin |
| Opioid OD | Naloxone |
| BZD OD | Flumazenil (avoid in TCA OD!) |
| Warfarin OD | Vitamin K + 4-Factor PCC |
| Heparin OD | Protamine Sulfate |
| Acetaminophen OD | N-Acetylcysteine (NAC) |
Good luck on your exam! You've got this! 💪
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What's inside the PDF (6 pages):
| Section | Content |
|---|---|
| Cover | Topic badges for all 13 sections |
| Autonomic Drugs | Flashcards for Adrenergic agonists/antagonists, Cholinergic agonists/antagonists + SLUDGE/DUMBELS mnemonic + "Mad as a Hatter" rule of 7 |
| Antipsychotics | 1st vs 2nd gen table, EPS timeline mnemonic ("4 A's in Order"), NMS emergency card |
| Antidepressants | SSRIs/TCAs/MAOIs/Other flashcards, TCA 3 C's, MAOI washout rules, Drug comparison table |
| SS vs NMS | Side-by-side comparison table + "Stop CBA" treatment mnemonic + Lithium toxicity levels |
| Cardio Drugs | ACEi/ARBs, Diuretics summary table (all 4 types), SGLT2i, Digoxin, CCBs, Nitrates, Beta Blockers, Antiarrhythmics full Vaughan Williams table, Amiodarone organ toxicity mnemonic, TdP treatment |
| Final Page | Complete antidotes reference table + 5 key antidote mnemonics |
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Topic : Autonomic drug(adrenergic and cholinergic drugs )
indications, conctraindications, side effects, toxicities and how to treat that.
Here are your complete, exam-ready notes on Autonomic Drugs. Everything is short, visual, and built to stick in 2 days.
🧠 AUTONOMIC DRUGS — EXAM NOTES
THE BIG PICTURE FIRST
AUTONOMIC NERVOUS SYSTEM
|
_____|_____
| |
SYMPATHETIC PARASYMPATHETIC
(Fight/Flight) (Rest/Digest)
Adrenaline=NE Acetylcholine=ACh
| |
ADRENERGIC CHOLINERGIC
DRUGS DRUGS
PART A: ADRENERGIC DRUGS
🔑 RECEPTOR CHEAT SHEET (Memorize This First!)
| Receptor | Location | Effect when stimulated |
|---|---|---|
| α1 | Blood vessels, eye, bladder | Vasoconstriction, mydriasis, urinary retention |
| α2 | Presynaptic (CNS) | ↓NE release → ↓BP (central) |
| β1 | Heart | ↑HR, ↑contractility |
| β2 | Lungs, uterus, vessels | Bronchodilation, vasodilation |
| D1/D2 | Kidney, brain | Renal vasodilation (low dose dopamine) |
Memory trick: β1 = 1 heart, β2 = 2 lungs
SECTION 1 — ADRENERGIC AGONISTS (Sympathomimetics)
"They STIMULATE the sympathetic system"
💊 EPINEPHRINE (Adrenaline)
Receptors: α1, α2, β1, β2 (hits ALL)
| ✅ USE | Anaphylaxis #1 · Cardiac arrest · Severe asthma · Croup (nebulized) |
| 🚫 AVOID | Hypertension · Tachyarrhythmias · Cocaine users · MAOI users |
| ⚠️ SE | ↑HR, ↑BP · Tremor · Anxiety · Headache · Hyperglycemia |
| ☠️ TOXICITY | Hypertensive crisis · MI · Stroke · Severe arrhythmias |
| 💊 TREAT TOX | α-blocker (Phentolamine) for HTN crisis · β-blocker for tachycardia |
💊 NOREPINEPHRINE (NE)
Receptors: α1, α2, β1 (NO β2)
| ✅ USE | Septic shock · Hypotension (vasopressor of choice in sepsis) |
| 🚫 AVOID | Hypovolemia (give fluids first!) · Peripheral vascular disease |
| ⚠️ SE | Severe vasoconstriction · Tissue necrosis if IV extravasates · Reflex bradycardia |
| ☠️ TOXICITY | Hypertensive crisis · Ischemia |
| 💊 TREAT TOX | Phentolamine (α-blocker) |
💊 DOPAMINE
Receptors: Dose-dependent (easy exam trick!)
LOW dose (1-5 mcg/kg/min) → D1 receptor → Renal vasodilation (↑urine output)
MID dose (5-10 mcg/kg/min) → β1 receptor → ↑HR, ↑contractility
HIGH dose (>10 mcg/kg/min) → α1 receptor → Vasoconstriction
| ✅ USE | Cardiogenic shock · Septic shock · Acute HF with hypotension |
| 🚫 AVOID | Pheochromocytoma · Tachyarrhythmias |
| ⚠️ SE | Tachycardia · Arrhythmias · Nausea/vomiting |
💊 DOBUTAMINE
Receptors: β1 (mainly) — "DObutamine DOes the heart"
| ✅ USE | Cardiogenic shock · Acute decompensated HF · Stress echocardiography |
| 🚫 AVOID | HOCM (hypertrophic obstructive cardiomyopathy) · Tachyarrhythmias |
| ⚠️ SE | Tachycardia · ↑myocardial O2 demand · Arrhythmias |
💊 PHENYLEPHRINE
Receptors: α1 ONLY (pure vasoconstrictor)
| ✅ USE | Nasal congestion (nasal spray) · Hypotension during anesthesia · Hemorrhagic shock |
| 🚫 AVOID | HTN · Use with MAOIs |
| ⚠️ SE | Reflex bradycardia · HTN · Urinary retention |
💊 CLONIDINE
Receptors: α2 (central) — "Clonidine Calms the CNS"
| ✅ USE | Hypertension · ADHD (2nd line) · Opioid/nicotine withdrawal · Menopausal hot flashes |
| 🚫 AVOID | Sick sinus syndrome · AV block · Combined with β-blockers |
| ⚠️ SE | Sedation · Dry mouth · Bradycardia · Constipation |
| ☠️ TOXICITY | Rebound HTN if stopped abruptly! (NEVER stop suddenly) |
| 💊 TREAT TOX | Gradual taper! Clonidine OD → Atropine + IV fluids + Naloxone (partially works) |
💊 ALBUTEROL
Receptors: β2 (lungs) — "Albuterol = Air = β2"
| ✅ USE | Asthma (rescue inhaler) · COPD bronchospasm · Hyperkalemia (shifts K+ into cells) · Premature labor (tocolytic) |
| 🚫 AVOID | Tachyarrhythmias · Thyrotoxicosis |
| ⚠️ SE | Tremor · Tachycardia · Hypokalemia (K+ shifts in) · Hyperglycemia |
⚡ ADRENERGIC AGONIST QUICK COMPARISON TABLE
| Drug | Receptors | #1 Use | Key SE |
|---|---|---|---|
| Epinephrine | ALL | Anaphylaxis | HTN crisis |
| Norepinephrine | α1,α2,β1 | Septic shock | Tissue necrosis |
| Dopamine | Dose-dependent | Shock | Arrhythmias |
| Dobutamine | β1 | Cardiogenic shock | Tachycardia |
| Phenylephrine | α1 | Nasal congestion | Reflex bradycardia |
| Clonidine | α2 (CNS) | HTN | Rebound HTN on stop |
| Albuterol | β2 | Asthma | Tremor, ↓K+ |
SECTION 2 — ADRENERGIC ANTAGONISTS (Sympatholytics)
"They BLOCK the sympathetic system"
💊 PRAZOSIN (α1-blocker)
| ✅ USE | Hypertension · BPH (relaxes bladder neck) · PTSD nightmares |
| 🚫 AVOID | Severe hypotension · Combined with PDE5 inhibitors (Sildenafil) |
| ⚠️ SE | FIRST-DOSE HYPOTENSION (take at bedtime!) · Dizziness · Nasal congestion · Reflex tachycardia |
Exam tip: First-dose hypotension = classic Prazosin question!
💊 PHENTOLAMINE (non-selective α-blocker)
| ✅ USE | Pheochromocytoma (surgery prep) · Hypertensive crisis from MAOIs or cocaine · Extravasation of vasopressors |
| ⚠️ SE | Hypotension · Reflex tachycardia |
💊 β-BLOCKERS — THE BIG GROUP
Memory trick for selectivity:
β1-selective (cardioselective) = "A-M-B-E" drugs:
Atenolol, Metoprolol, Bisoprolol, Esmolol
Non-selective (β1+β2) = Propranolol, Nadolol, Timolol
α+β blockers = Labetalol, Carvedilol
| ✅ USE | HTN · Angina · Post-MI (↓mortality, mandatory!) · HFrEF (Carvedilol, Metoprolol, Bisoprolol) · AFib rate control · Migraine prophylaxis (Propranolol) · Essential tremor · Thyrotoxicosis symptoms · Glaucoma (Timolol eye drops) |
| 🚫 AVOID | Asthma/COPD (non-selective cause bronchospasm) · 2nd/3rd degree AV block · Acute decompensated HF · Cocaine users · Pheochromocytoma (without α-blockade first!) · NEVER STOP ABRUPTLY → rebound angina/MI |
| ⚠️ SE | Bradycardia · Fatigue · Cold extremities · Sexual dysfunction · Depression (Propranolol, CNS-penetrating) · MASKS hypoglycemia (hides tachycardia & tremor — sweating preserved!) · Hypertriglyceridemia |
| ☠️ TOXICITY | Bradycardia + Hypotension + AV block + Bronchospasm + Cardiogenic shock |
β-Blocker Overdose Treatment (in order):
1. GLUCAGON IV (DRUG OF CHOICE — bypasses β-receptor, ↑cAMP)
2. Atropine (for bradycardia — often not enough alone)
3. High-dose Insulin + Dextrose (HIET)
4. Calcium IV
5. Vasopressors (Epi, NE, Dopamine)
6. Temporary pacemaker if refractory
7. ECMO for refractory shock
PART B: CHOLINERGIC DRUGS
🔑 RECEPTOR CHEAT SHEET
| Receptor | Location | Effect |
|---|---|---|
| Muscarinic (M) | Heart, smooth muscle, glands, eye | ↓HR, secretions, miosis, GI motility |
| Nicotinic (Nm) | Neuromuscular junction | Muscle contraction |
| Nicotinic (Nn) | Autonomic ganglia | Both sympathetic & parasympathetic |
SECTION 3 — CHOLINERGIC AGONISTS (Parasympathomimetics)
💊 BETHANECHOL (Muscarinic agonist, M-receptor)
| ✅ USE | Urinary retention (post-op, neurogenic) · Paralytic ileus |
| 🚫 AVOID | Asthma/COPD · GI/bladder obstruction · Peptic ulcer · Bradycardia |
| ⚠️ SE | SLUDGE symptoms (see mnemonic below) |
💊 PILOCARPINE (Muscarinic agonist)
| ✅ USE | Glaucoma (eye drops — contracts ciliary muscle, opens drainage) · Dry mouth/Sjögren's syndrome · Xerostomia after radiation |
| 🚫 AVOID | Asthma · Acute angle-closure glaucoma (used to TREAT it, but if in doubt) |
| ⚠️ SE | Sweating · Blurred vision · Bradycardia |
💊 NEOSTIGMINE & PYRIDOSTIGMINE (AChE Inhibitors — reversible)
They block acetylcholinesterase → ACh accumulates → prolonged cholinergic effect
| ✅ USE | Myasthenia Gravis (Pyridostigmine = drug of choice) · Reversal of neuromuscular blockade (Neostigmine) · Post-op urinary retention · Post-op ileus |
| 🚫 AVOID | GI/urinary obstruction · Asthma |
| ⚠️ SE | SLUDGE · Bradycardia · Muscle cramps |
| 🧠 KEY FACT | Neostigmine does NOT cross BBB (peripheral only) |
💊 PHYSOSTIGMINE (AChE Inhibitor — reversible, CROSSES BBB)
| ✅ USE | Antidote for anticholinergic toxidrome (delirium, hallucinations) · Glaucoma (eye drops) |
| 🚫 AVOID | Asthma · TCA overdose (can worsen seizures!) |
| 🧠 KEY FACT | ONLY AChE inhibitor that crosses BBB → treats CNS anticholinergic effects |
💊 ORGANOPHOSPHATES (Irreversible AChE inhibitors)
Examples: Nerve agents (Sarin), Insecticides (Malathion, Parathion)
| Mechanism | Irreversibly bind AChE → ACh floods everywhere |
| Toxicity | CHOLINERGIC CRISIS |
| ☠️ TREAT | ATROPINE (high doses, blocks muscarinic) + PRALIDOXIME (2-PAM) — must give EARLY before "aging" |
🧠 MASTER MNEMONIC: CHOLINERGIC TOXICITY
SLUDGE (Muscarinic effects)
S — Salivation
L — Lacrimation
U — Urination
D — Defecation
G — GI distress
E — Emesis
DUMBELS (Same thing, more complete)
D — Diarrhea
U — Urination
M — Miosis
B — Bradycardia
E — Emesis
L — Lacrimation
S — Salivation
(+ Bronchospasm + Bronchorrhea + Seizures)
SECTION 4 — CHOLINERGIC ANTAGONISTS (Antimuscarinics/Anticholinergics)
"They BLOCK acetylcholine at muscarinic receptors"
💊 ATROPINE (Prototype antimuscarinic)
| ✅ USE | Bradycardia · Organophosphate poisoning (antidote) · Pre-op (↓secretions) · AV block (1st/2nd degree type I) · Peptic ulcer (↓acid) |
| 🚫 AVOID | Closed-angle glaucoma (↑IOP) · BPH/urinary retention · Tachyarrhythmias · Myasthenia gravis · GI obstruction |
| ⚠️ SE | See "Mad as a Hatter" mnemonic below |
💊 SCOPOLAMINE
| ✅ USE | Motion sickness (transdermal patch) · Post-op nausea |
| ⚠️ SE | Dry mouth · Drowsiness · Blurred vision |
💊 IPRATROPIUM & TIOTROPIUM (Inhaled antimuscarinics)
| ✅ USE | COPD (1st line) · Asthma (add-on) · Ipratropium: acute bronchospasm |
| ⚠️ SE | Dry mouth (main) · Urinary retention (watch in elderly men with BPH) |
| 🧠 KEY FACT | Tiotropium = long-acting (once daily) · Ipratropium = short-acting |
💊 OXYBUTYNIN (& Tolterodine, Solifenacin)
| ✅ USE | Overactive bladder / urge incontinence |
| 🚫 AVOID | Urinary retention · Glaucoma · Elderly (cognitive impairment — Beers criteria) |
| ⚠️ SE | Dry mouth (most common & most bothersome) · Constipation · Blurred vision · Urinary retention |
💊 BENZTROPINE (& Trihexyphenidyl)
| ✅ USE | Parkinson's disease (controls tremor & rigidity) · EPS from antipsychotics (acute dystonia) |
| 🚫 AVOID | Elderly · Dementia · Closed-angle glaucoma |
| ⚠️ SE | Dry mouth · Urinary retention · Confusion in elderly |
🧠 MASTER MNEMONIC: ANTICHOLINERGIC TOXICITY
"MAD AS A HATTER" — 7 Signs
HOT as a hare → Hyperthermia (no sweating = can't cool down)
DRY as a bone → Dry mouth, anhidrosis, constipation
RED as a beet → Flushing (vasodilation)
BLIND as a bat → Mydriasis (big pupils), blurred vision
MAD as a hatter → Confusion, delirium, hallucinations
FULL as a flask → Urinary retention
FAST as a fiddle → Tachycardia
Anticholinergic Toxidrome Treatment:
1. PHYSOSTIGMINE IV (antidote — crosses BBB, treats delirium)
BUT avoid in TCA overdose!
2. Benzodiazepines (agitation, seizures)
3. Cooling measures (ice, cool IV fluids) for hyperthermia
4. Urinary catheter if retention
5. Supportive care
CHOLINERGIC ANTAGONIST DRUG SUMMARY
| Drug | Main Use | Key Memory Hook |
|---|---|---|
| Atropine | Bradycardia, OP poisoning | "A for Antidote" |
| Scopolamine | Motion sickness | "Scope the sea" (patch behind ear) |
| Ipratropium | COPD (short-acting) | "I = Inhaled, short" |
| Tiotropium | COPD (long-acting) | "Ti = long TIme" |
| Oxybutynin | Overactive bladder | "Oxy = OAB" |
| Benztropine | Parkinson tremor, EPS | "Benz = Brain tremor" |
| Physostigmine | Anticholinergic antidote | "Physo = Fixes the brain" |
⚡ TOXICITY TREATMENTS — MASTER TABLE
| Toxidrome | What happens | ANTIDOTE |
|---|---|---|
| Adrenergic/Sympathomimetic crisis | ↑BP, ↑HR, arrhythmias, stroke | Phentolamine (α-blocker) + β-blocker |
| β-Blocker overdose | Bradycardia, hypotension, AV block | GLUCAGON IV (1st line!) |
| Cholinergic crisis (organophosphate) | SLUDGE + seizures + paralysis | ATROPINE (high dose) + Pralidoxime (2-PAM) |
| Anticholinergic toxidrome | Mad as a hatter signs | PHYSOSTIGMINE IV |
| Cocaine toxicity | HTN, tachycardia, coronary spasm | Phentolamine/Nitroprusside — NEVER β-blocker alone |
| Clonidine OD | Bradycardia + hypotension | Atropine + Naloxone + IV fluids |
🏆 TOP 10 EXAM PEARLS
- Epinephrine = #1 drug for anaphylaxis (IM thigh)
- Prazosin = first-dose hypotension → tell patient to take at bedtime
- β-blocker OD antidote = GLUCAGON (not atropine alone!)
- Cocaine toxicity → NEVER give β-blocker alone → unopposed α = worse HTN
- Organophosphate antidote = Atropine + Pralidoxime (give 2-PAM EARLY before aging!)
- Anticholinergic antidote = Physostigmine (crosses BBB unlike Neostigmine)
- Clonidine = rebound HTN if stopped suddenly → TAPER slowly
- Albuterol treats hyperkalemia (shifts K+ into cells temporarily)
- Pilocarpine = glaucoma + dry mouth/Sjögren's
- Physostigmine crosses BBB; Neostigmine does NOT → use Physostigmine for CNS anticholinergic symptoms
📌 LAST-MINUTE 2-MINUTE REVIEW
ADRENERGIC AGONISTS:
Epi → ALL receptors → Anaphylaxis
NE → α+β1 → Septic shock
Dopamine → dose-dependent
Dobutamine → β1 → cardiogenic shock
Phenylephrine → α1 → nasal decongestion
Clonidine → α2 central → HTN (don't stop suddenly!)
Albuterol → β2 → Asthma
ADRENERGIC ANTAGONISTS:
Prazosin → α1 block → HTN + BPH (1st dose hypotension!)
Phentolamine → α block → pheo + MAOI crisis
β-blockers → post-MI, HF, HTN; OD Rx = GLUCAGON
CHOLINERGIC AGONISTS:
Bethanechol → M → urinary retention
Pilocarpine → M → glaucoma, dry mouth
Neostigmine → AChE inhibit → MG, NMB reversal (no BBB)
Physostigmine → AChE inhibit → anticholinergic antidote (CROSSES BBB)
Organophosphates → irreversible AChE → CHOLINERGIC CRISIS → Atropine + 2-PAM
CHOLINERGIC ANTAGONISTS:
Atropine → bradycardia, OP antidote
Ipratropium/Tiotropium → COPD
Oxybutynin → OAB
Benztropine → Parkinson/EPS
TOXIDROME → "Mad as a Hatter" → Rx: Physostigmine
You've got this! Focus on the mnemonics and toxicity treatments — those are the highest-yield exam questions. Want me to cover the next topic now? 💪
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