Pharmacology 00 / 21 , all cards and bookmarks
Dosing by weight, age and organ function 01 / 21 Scale every dose to this patient: weight scalar, age, kidneys and brain each change it.
Depth decides the reversal 02 / 21 Count twitches first: deep block sugammadex, four twitches neostigmine; extubate only at a ratio of 0.9.
Reversal by depth of block Relaxant and depth Reversal Cisatracurium, fewer than four twitches → , open its explanation Do not reverse yet; ventilate until four twitches Cisatracurium, four twitches → , open its explanation Neostigmine 40–50 mcg/kg plus antimuscarinic; confirm quantitatively Rocuronium, train‑of‑four zero, post‑tetanic 1–2 → , open its explanation Deep block: sugammadex 4 mg/kg Rocuronium given, failed intubation, decision to wake → , open its explanation Sugammadex 16 mg/kg; failed oxygenation needs front‑of‑neck access Rocuronium, train‑of‑four ratio under 0.9 after neostigmine → , open its explanation Stay intubated; give sugammadex Rocuronium, ratio under 0.9, neostigmine top‑up → , open its explanation At most 50 mcg/kg total (ASA); stay intubated
Sugammadex binding strength Report a problem with card 2: Depth decides the reversal
Minimum alveolar concentration (MAC): what moves it 03 / 21 MAC falls with age, pregnancy, cold, lithium and depressants; rises with heat, sodium and chronic alcohol.
The medicine list 04 / 21 Check the medicine list first: it bars a drug, changes a level or forbids an antidote.
Antidepressants and opioids Other medicines and herbal remedies Methaemoglobinaemia and methylene blue Report a problem with card 4: The medicine list
Relaxant choice: give, avoid, prevent 05 / 21 Succinylcholine is barred by myopathy, burns past 24 hours or cholinesterase defect; pretreat its side effects.
Choosing the relaxant Clinical setting Relaxant decision Myotonic dystrophy or other myopathy → , open its explanation Avoid succinylcholine; myasthenia gravis is not a contraindication Burns within the first 24 hours → , open its explanation Succinylcholine safe Burns past 24 hours, hyperkalaemia peak 7–10 days → , open its explanation Avoid succinylcholine Burns, non‑depolariser needed → , open its explanation Expect resistance; give bigger doses Prolonged recovery after esterase‑cleared drug → , open its explanation Plasma cholinesterase deficiency: avoid mivacurium and succinylcholine Re‑paralysis soon after sugammadex → , open its explanation Urgent: succinylcholine; non‑urgent: benzylisoquinolinium; standard rocuronium waits 4 hours Glaucoma, intact globe → , open its explanation Succinylcholine allowed; rise peaks 2–4 minutes, gone by 6
Preventing succinylcholine side effects Report a problem with card 5: Relaxant choice: give, avoid, prevent
Drug for the job 07 / 21 Match the drug to the task, not to habit.
Drug for the task The drug that ranks first Property Drug Benzodiazepine with shortest elimination half‑life → , open its explanation Midazolam, not lorazepam or alprazolam Largest fall in cerebral metabolic rate → , open its explanation Thiopental or propofol, about 60% at burst suppression Strongest mydriasis and sedation → , open its explanation Scopolamine, then atropine; not glycopyrrolate Strongest drying of salivary secretions → , open its explanation Glycopyrrolate, over atropine and scopolamine Least effect on urine output → , open its explanation Fentanyl; volatile agents reduce it Strongest anti‑inflammatory steroid for joint injection → , open its explanation Betamethasone (potency 25)
Report a problem with card 7: Drug for the job
Monitoring the block 09 / 21 Only a measured train-of-four ratio of 0.9 proves recovery; touch and clinical signs miss residual block.
Depth, EEG and stages 10 / 21 Read depth from the EEG and the breathing; ketamine fools the bispectral index (BIS).
Drug syndromes and their antidotes 11 / 21 Name the drug effect from its signs, then give its antidote, stop the drug, or observe.
Recognising the syndrome Signs Syndrome Confusion, blurred vision, dryness after scopolamine or atropine → , open its explanation Central anticholinergic syndrome Propofol ≥4 mg/kg/h 48 hours: bradycardia, acidosis → , open its explanation Propofol infusion syndrome Open eyes, nystagmus, dilated pupils after ketamine → , open its explanation Normal dissociative picture, not a complication Serotonergic drugs: fever, sweating, clonus, myoclonus, hyperreflexia → , open its explanation Serotonin syndrome; not neuroleptic malignant syndrome, malignant hyperthermia New rigidity after metoclopramide in Parkinson's disease → , open its explanation Worsened parkinsonism from dopamine receptor blockade Eyes rolled up, twisted neck after droperidol → , open its explanation Acute dystonia
Managing each syndrome Report a problem with card 11: Drug syndromes and their antidotes
The drug behind the finding 12 / 21 Work back from the finding to the one drug that causes it.
Finding Drug Intravenous opioid causing profound hypotension, flushing → , open its explanation Codeine (morphine, pethidine also release histamine) Sedated with dilated pupils after an opioid → , open its explanation Pethidine (meperidine) Junctional bradycardia at induction in Down syndrome → , open its explanation Sevoflurane Venous thromboembolism on breast‑cancer drugs → , open its explanation Tamoxifen Pneumonitis on chemotherapy, can progress to fibrosis → , open its explanation Bleomycin Seizure in a fasting diabetic → , open its explanation Insulin; check glucose Nasal decongestant drops, severe hypertension, slow pulse → , open its explanation Phenylephrine Relaxant losing potency unrefrigerated → , open its explanation Succinylcholine (rocuronium stable 60 days, pancuronium 6 months) Hallucinations on emergence from multimodal analgesia → , open its explanation Ketamine
Report a problem with card 12: The drug behind the finding
Blood pressure crisis from a drug 14 / 21 Hypertension after eye drops, stimulants or stopped clonidine is drug-driven: remove the cause, treat the pressure.
Picture Cause and response Hypertension, reflex bradycardia after phenylephrine eye drops → , open its explanation Phentolamine or a direct vasodilator; never a beta‑blocker Hypertension, tachycardia, ischaemia in a cocaine user → , open its explanation Acute cocaine intoxication; lasting risks: cardiomyopathy, arrhythmia, stroke Hypertension, tachycardia despite generous opioid, amphetamine user → , open its explanation Acute intoxication: expect a raised anaesthetic requirement Hypertensive crisis with tachycardia after antihypertensive stopped → , open its explanation Clonidine withdrawal (8–36 h); continue clonidine perioperatively
Sources: AHA/ACC 2024 · §7.4
Report a problem with card 14: Blood pressure crisis from a drug
What prolongs or shortens the block 15 / 21 Age, cold, respiratory acidosis, magnesium, volatiles and aminoglycosides prolong block; calcium shortens, total intravenous anaesthesia (TIVA) spares.
What prolongs the block or blunts reversal What shortens the block or lowers residual risk Report a problem with card 15: What prolongs or shortens the block
Apnoea from an opioid interaction 16 / 21 Opioid apnoea means more active drug: fast metaboliser, enzyme inhibitor, warmed patch or sensitive neonate.
Situation Cause Sedation after codeine post‑tonsillectomy → , open its explanation Morphine rise from ultra‑rapid CYP2D6 Codeine gives poor analgesia → , open its explanation Slow CYP2D6 metaboliser: little morphine formed Breastfed neonate lethargic on maternal codeine → , open its explanation Mother an ultra‑rapid CYP2D6 metaboliser Codeine added to a fentanyl patch: apnoea → , open its explanation CYP2D6 converts codeine to morphine Apnoea after fentanyl added to methadone → , open its explanation Additive opioid effect; enzyme named: fentanyl's CYP3A4 Apnoea after normal‑dose fentanyl in preterm neonate → , open its explanation More free fentanyl: low protein, bilirubin competition, immature barrier Warming blanket or heat pack over fentanyl patch → , open its explanation Keep heat off patch; continue or replace, never remove
Report a problem with card 16: Apnoea from an opioid interaction
Context-sensitive half-time 18 / 21 Offset after an infusion grows with its length: fentanyl and dexmedetomidine most, propofol little, remifentanil never.
Volatile agents and gases 19 / 21 Solubility sets speed, lipid solubility sets potency; each agent has its own effects.
Drug, class and receptor 20 / 21 Name the class or receptor; the class predicts the effect.
Vaughan Williams classes (Lei 2018) and their official name endings Class · name ending Blocks · ECG · drugs Class Ia · -cain- → , open its explanation Sodium · wider QRS, longer QT · quinidine, procainamide, disopyramide Class Ib · -cain- → , open its explanation Sodium, weakest · little effect on normal tissue · lidocaine, mexiletine Class Ic · -cain- → , open its explanation Sodium, strongest · much wider QRS · flecainide, propafenone Class II · -olol → , open its explanation Beta receptors · slower rate, longer PR · esmolol Class III · -ilide → , open its explanation Potassium · longer QT · amiodarone, bretylium, sotalol, dofetilide Class IV · no ending → , open its explanation Nodal calcium channels · longer PR · verapamil, diltiazem Exception: sotalol → , open its explanation Ends in -olol, yet class III: potassium block dominates Outside the four classes → , open its explanation Adenosine, digoxin, magnesium
Drug classes Drug Class Ethacrynic acid → , open its explanation Loop diuretic without a sulfonamide group Nalbuphine → , open its explanation Mixed opioid agonist–antagonist Milrinone → , open its explanation Phosphodiesterase III inhibitor; no adrenoceptor action Hydralazine → , open its explanation Direct systemic arterial vasodilator Sarin → , open its explanation Irreversible acetylcholinesterase inhibitor Vecuronium, rocuronium, pancuronium → , open its explanation Aminosteroid non‑depolarising blocker; sugammadex reverses Atracurium, cisatracurium, mivacurium, tubocurarine → , open its explanation Benzylisoquinolinium non‑depolarising blocker; more histamine
Receptor and channel targets Effects to expect Drug Effect to expect Ketamine alone → , open its explanation Bronchodilator, tachycardia, more saliva; breathing kept unless sedatives added Angiotensin‑converting enzyme (ACE) inhibitor → , open its explanation Natriuresis: an indirect diuretic ACE inhibitor → , open its explanation Lowers afterload; raises cardiac output, renal flow Fenoldopam → , open its explanation Dopamine D1 vasodilator; alternative to nitroprusside Sodium nitroprusside → , open its explanation Impairs platelet aggregation; raises intracranial pressure; cyanide risk Hydralazine → , open its explanation Reflex tachycardia beyond baroreflex; avoid in ischaemic heart disease Anticholinesterase at the motor nerve ending → , open its explanation Longer terminal action potential; repetitive firing Sarin → , open its explanation Cholinergic crisis at muscarinic and nicotinic receptors
Autonomic transmitters Report a problem with card 20: Drug, class and receptor
Traps Check these before you finish 1 card · about 1 min 21 Traps
Traps 21 / 21 The tempting call is the familiar one; the books often name another.
Tempting Right call Glaucoma: succinylcholine absolutely contraindicated → , open its explanation Succinylcholine allowed; open globe only with deep anaesthesia, full block Scopolamine for strongest drying of secretions → , open its explanation Glycopyrrolate: most potent antisialagogue, less tachycardia than atropine Preterm fentanyl apnoea: immature barrier keeps drug out → , open its explanation Excess free fentanyl reaching brain, not kept out Promethazine for nausea in Parkinson's disease → , open its explanation Ondansetron; promethazine is contraindicated Vecuronium for re‑paralysis after sugammadex → , open its explanation Urgent: succinylcholine; otherwise benzylisoquinolinium. Vecuronium waits 4 hours Fentanyl for normal BIS despite anaesthesia → , open its explanation Nitrous oxide (barely moves BIS) or ketamine (raises it) Green urine as a propofol infusion syndrome sign → , open its explanation Harmless propofol effect; not a syndrome feature Echothiopate as a prolonger of non‑depolarising block → , open its explanation Prolongs succinylcholine and mivacurium, the plasma‑cholinesterase substrates Tramadol as mild opioid with MAO inhibitor → , open its explanation Avoid tramadol, pethidine, methadone; choose morphine Succinylcholine and rocuronium both on total weight → , open its explanation Succinylcholine total body weight; rocuronium lean weight At two twitches, give neostigmine 50 mcg/kg together with atropine → , open its explanation Ventilate until four twitches, then neostigmine 40–50 mcg/kg Plasma cholinesterase rises in pregnancy → , open its explanation Falls 20–30%; succinylcholine slightly prolonged, clinically trivial
Report a problem with card 21: Traps
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Sheet 03 · Pharmacology 21 / 21
That is Pharmacology, all 21 cards.
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