Autonomic Nervous System

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Autonomic Nervous System

• Chapter 16, 17, 18, 19, 20
• Clinical Drug Therapy

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Nervous System

• Two main divisions
• Central Nervous System or CNS
• Peripheral Nervous System or PNS

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Central Nervous System or CNS

• Brain and spinal cord receives and processes
  incoming sensory information and responds by
  sending out signals that initiate or modify a
  process.

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Peripheral Nervous System or PNS

• Includes all the neurons and ganglia found
  outside the CNS
• Afferent (sensory) modify motor output
• Efferent

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Afferent Neurons

• Afferent neurons carry sensory input from the
  periphery to the CNS and modify motor output
  through the reflex arc.

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Efferent Neurons

• Efferent neurons carry motor signals from the CNS
  to the peripheral areas of the body.

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ANS / SNS

• Autonomic nervous system controls involuntary
  activities of smooth muscle, secretory glands and
  the visceral organs of the body such as the heart
  (involuntary activities of smooth muscle)
• Somatic nervous system innervates the skeletal
  muscles and controls voluntary movement

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Autonomic Nervous System

• Sympathetic Nervous System
• Para sympathetic System
• Enteric System

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The Race Horse and the Cow
Sympathetic Nervous System
Parasympathetic
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Sympathetic System

• Fight or Flight stimulated by physical or
  emotional stress (exercise or work), pain,
  hemorrhage, intense emotions, temperature
  extremes

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Sympathetic Nervous System

• Protective mechanisms designed to help person
  cope with the stress or get away from it.

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Neurotransmitters

• Neurotransmitters
• Acetylcholine skeletal muscle
• Norepinepherine stress response

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Norepinephrine and epinephrine

• Both always present in the blood.
• Norepinephrine varies according to the amount of
  stress present and will cause transient changes
  in heart rate and systemic arteries and veins.
• Epinephrine is a constant in regulating heart
  rate, vasoconstriction in systemic arteries and
  veins and vasodilation of muscles and liver.

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Dopamine

• Adrenergic neurotransmitter essential for
  normal brain function.
• Studies focus on connection between dopamine
  malfunction in schizophrenia and Parkinsons
  Disease.
• Role of dopamine in drug addition to drugs
  stimulants and depressants.

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Protective Mechanisms

• Intensity of response depends on Norepinephrine
  and epinephrine
• Fight or flight

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Body Responses

• Increase in blood pressure and cardiac output.
• Increase blood flow to brain, heart and skeletal
  muscles.
• Decrease blood flow to skin and organs not needed
  for flight.
• Increase in glycogen for energy, mental activity,
  muscle strength, blood coagulation, respiratory
  rate, pupil dilation to aid vision, and increase
  in sweating.

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Fight of Flight Response

• Can be a problem if the body stay in the fight
  or flight mode.
• Type A personalities?
• High stress environment?
• Medications may be needed reduce the physiologic
  body responses.

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Parasympathetic Nervous System

• Rest and Digest
• Save energy
• Decreased heart rate

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Adrenergic Receptors

• Norepinephrine and epinephrine interact with two
  adrenergic receptors
• Alpha and beta
• Alpha 1
• Alpha 2
• Beta 1
• Beta 2

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Alpha 1

• Alpha 1 receptors allows calcium ions to move
  into the cell and produce muscle contraction.

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Alpha 1

• Location
• Blood vessels
• Kidney
• Intestinal smooth muscles
• Genitourinary
• Eyes blinking
• Pregnant uterus contractions
• Male sexual organs sexual function

• Effects of stimulation
• Vasoconstriction
• Release of renin (kidney)
• Relaxation

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Alpha 2

• Location
• Nerve endings
• Vascular smooth muscles
• Pancreatic beta cells
• Platelets

• Effects of stimulation
• Inhibits release of Norepinephrine
• Vasoconstriction
• Inhibit insulin secretion
• Aggregation or clotting

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Beta 1

• Location
• Heart
• Kidneys

• Effects of stimulation
• Increase heart rate, force of contraction,
  automaticity and rate of atrial-ventricular
  function
• Increased renin release

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Beta 2

• Location
• Bronchioles
• Blood vessels
• Gastrointestinal tract
• Liver
• Urinary bladder
• Pregnant uterus

• Effects of stimulation
• Vasodilation
• Decreased motility and tone
• Glycogenolysis
• Relaxed detrusor muscle (bladder muscle)
• Relaxation of uterus

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Dopamine

• Location
• Blood vessels of kidney, heart, and other viscera

• Effects of stimulation
• Vasodilation

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Parasympathetic Nervous System

• Functions stimulated by PNS Resting, reparative,
  or vegetative function

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Body Responses

• Dilation of blood vessels in skin
• Decrease heart rate (bradycardia)
• Increase secretion of digestive enzymes
• Constriction of smooth muscle of bronchi
• Increase in sweat glands
• Contraction of smooth muscles of urinary bladder
• Contraction of smooth muscle of skeletal system

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Neurotransmitter

• Acetylcholine
• Two types of cholinergic receptors
• Nicotinic located in motor nerves and skeletal
  muscles
• Muscarinic located in internal organs,
  cardiovascular, respiratory, GI and GU

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Autonomic Drugs

• Drugs used due to their ability to stimulate or
  block activity of the sympathetic or
  parasympathetic nervous system.

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Effect of Drugs

• Drugs that act of ANS usually affect the entire
  body.
• Effects depend on whether you are trying to
  stimulate or inhibit function.

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Receptor Activity

• Drugs are developed to stimulate or inhibit
  particular subtypes of receptors.
• More selective on particular body tissues.
• Decrease adverse effects on other body tissues
  side effects.

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Simulation of SNS

• Stimulation of sympathetic nervous system can be
  divided into drug classifications
• Adrenergic
• Sympathomimetic
• Alpha and beta adrenergic agonists

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Agonist

• In pharmacology an agonist is a substance that
  binds to a specific receptor and triggers a
  response in the cell.

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Blockage of SNS

• Drugs that inhibit sympathetic nervous system are
  classified as
• Antiadrenergic
• Sympatholytic anticholinergic

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Stimulation of PNS

• Parasympathetic nervous system stimulation drug
  classifications
• Cholinergic
• Parasympathomimenic
• Cholinomimetic

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Blocking of PNS

• Drugs that inhibit parasympathetic stimulation
  are classified as
• Anticholinergic
• Parasympatholytic
• Cholenergic blocking drugs

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Classifications SNS

• Sympathetic nervous system drug classifications
• Adrenergic - stimulating
• Antiadrenergic - blocking

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Classifications PNS

• Parasympathetic nervous system drugs
• Cholinergic
• Anticholinergic

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Adrenergic Drugs

• Chapter 17

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Adrenergic Drugs

• What do they do?
• Stimulation of the sympathetic nervous system.

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Mechanism of Action

• Three mechanisms
• Directly with alpha 1 or beta-adrenergic
  receptors on surface membrane.
• Indirect effects of postsynaptic adrenergic
  receptors.
• Mixed action combination of action on direct
  and indirect receptor.

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Heart

• Direct stimulation of receptors
• Alpha 1 - Vasoconstriction of blood vessels which
  increases blood pressure pressor or vasopressor
  effect.
• Beta 2 - increased force of myocardial
  contraction - Increased speed of electrical
  conduction in the heart.

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Lungs

• Asthma and COPD (Chronic Obstructive Pulmonary
  Disease) Beta 2 drugs or bronchodilators are
  used to relieve broncho-constriction and
  broncho-spasm.

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Pregnancy

• Adrenergic drugs used to relax uterine muscles in
  preterm labor.

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OTC Adrenergic Drugs

• Common cold anti-histamines
• Allergy nasal or oral to relieve nasal
  congestion

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Adrenergic Drugs

• Epinephrine
• Pseudoephedrine Sudafed
• Isoproterenol (Isuprel)
• Phenylephrine (Neo-Synephrine)
• Clonidine (antihypertensive)

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How does one choose a drug?

• How emergent is the situation
• PO or IM or IV

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Allergic Response

• Runny nose, itchy eyes, cough
• Asthma Cough with bronchospasms, difficulty
  breathing or SOB (shortness of breath)
• Anaphylactic shock edema of airway

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Allergy Response

• Nasal congestion, itchy eyes, non-productive
  cough
• Seasonal response to environmental causes
• Commonly mixed with other drugs in cold
  medications

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Pseudoephedrine

• Therapeutic classification allergy, cold, and
  cough remedies, nasal drying, and decongestants.
• Indications symptomatic management of nasal
  congestion associated with acute viral upper
  respiratory tract infection. Most often used in
  combination with other drugs.
• Action stimulates Alpha and beta-adrenergic
  receptors vasoconstriction in respiratory tract
  mucosa possible bronchodilation
• Therapeutic effects reduction of nasal
  congestion, and swelling of nasal passages.

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Forms and Dosage

• How supplied tabs, chew tabs, extended release
  tabs, liquid or drops
• Dosing 30 to 60 mg / dose q 6-8 hours PO
• Maximum dose 240 mg/24 hours
• Sustained release 120 mg PO q 12 hours

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Contraindications

• Severe Hypertension
• Severe CAD / coronary artery disease
• Use with caution in pregnancy, breast feeding and
  renal failure

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Use with caution!

• Mild or moderate hypertension, hyperglycemia,
  hyperthyroidism, and cardiac disease.

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Side Effects

• Dizziness, nervousness, restlessness, insomnia
  and arrhythmias
• Seizures
• Cardiovascular collapse

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Additional Information

• OTC used in combination with anti-histamines
• Primarily excreted renally adjust in patients
  with renal impairment
• May cause false-positive for amphetamines
  athletes
• Currently need to ask pharmacist for Sudafed
  OTC has been limited due to abuse

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Nursing Implications

• Assess for congestion
• Monitor pulse and blood pressure before beginning
  therapy
• Assess lung sound for signs of bronchial
  secretions

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Severe Anaphylactic Shock

• Usually involving the airways
• Some thing as simple as food allergy can trigger
  it
• Peanuts, shell fish, legumes, bee sting,
  medications
• Symptoms usually starts with numbness and
  tingling of lips and leads to swelling of the
  glottis or epiglottis this can result in
  closure of the airway.

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How Do You Treat It?

• Epinephrine would be the drug of choice
• Classification adrenergic
• Action affects both the beta (cardiac) and beta
  (pulmonary) receptors produces bronchodilation
  inhibits hypersensitivity reaction of mast
  cells.

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Epinephrine

• Therapeutic Effects
• Bronchodilation
• Maintenance of heart rate and blood pressure
• Adverse Side Effects
• Nervousness, restlessness, tremors, angina,
  arrhythmias, hypertension, tachycardia

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How it is given?

• Sub-Q or IV or inhaled
• The subcutaneous or intramuscular administration
  will help it to get into the blood stream quicker
  epi-pen is given to clients with severe allergy
  reactions
• Not given by mouth because drug is inactivated by
  gastric juices
• Can be inhaled in asthma attack

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CAUTION!

• Check dose, concentration, and route of
  administration fatalities have occurred from
  medication errors us TB syringe for
  subcutaneous administration
• Inhaled provided as metered dose inhaler 160 to
  250 mcg broncho-constriction is asthma
• IV would be 0.1 to 0.25 mg (cardiopulmonary
  resuscitation)

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Precautions with Use

• Tachyarrhythmia's (fast irregular heart rate),
  headache, nausea, and palpitations
• Short acting so more definitive treatment needs
  to be initiated
• Need cardio-respiratory monitoring
• Pulse oximetry
• Cardiac monitor

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Cardiac Arrest

• Epinephrine is the best studied and most
• widely administered adrenergic agonist used
• for the treatment of cardiac arrest.
• Used to jump start the heart.

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Vasopressor / Inotropic Drugs

• Used extensively along with Dopamine to maintain
  myocardial and cerebral perfusion post cardiac
  arrest.
• Administered in small, consistent amounts
  intravenous.

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Antiadrenergic Drugs

• Chapter 18
• Clinical Drug Therapy

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Antiadrenergic Drugs

• Blocks the effects of the sympathetic nerve
  stimulation, endogenous catecholamine and
  adrenergic drugs.

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Mechanism of Action

• Act on alpha or beta receptors
• Receptors are blocked by adrenergic antagonists
  or pre-synaptic alpha 2 receptors are stimulated.

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When Used?

• To manage hypertension and a number of
  cardiovascular disorders.

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Anti hypertensive Medication

• Clonidine Catapres, Catapres TTS, Dixarit,
  Duracion
• Pharmacologic classification adrenergic
  (centrally acting)
• Therapeutic classification antihypertensive

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Clonidine

• Action Stimulates the alpha-adrenergic receptors
  in the CNS which results in decreased sympathetic
  outflow inhibiting cardioacceleration and
  vasoconstriction centers. Prevents pain signal
  transmission to the CNS by stimulating
  alpha-adrenergic receptors in the spinal cord.
• Therapeutic Effects decreased blood pressure.
  Decreased pain.

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Cholinergic Drugs

• Chapter 19
• Clinical Drug Therapy

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Cholinergic Drugs

• Cholinergic drugs stimulate the parasympathetic
  nervous system.

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Mechanism of Action

• Direct acting cholinergic drugs are synthetic
  derivative of choline.
• Effects of drug
• Decrease heart rate, vasodilation, and changes in
  BP
• Increase tone and contractibility of smooth
  muscle
• Increase tone and contractibility of bronchial
  smooth muscles
• Increased respiratory secretions

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Indications for Use

• Urinary retention without obstruction
• Postoperative abdominal distention due to
  paralytic ileus
• Myasthenia gravis muscle weakness
• During surgery to reverse the effects of muscle
  relaxants used during surgery

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Nursing Assessment urine retention

• Urinary retention
• Bladder distention
• Fluid intake
• Time of last void
• How do you know drug is working?
• Fluid intake equal to urine output
• Patient has voided within the last 8 hours

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Nursing Assessment paralytic ileus

• Paralytic ileus
• Hypo-peristalsis
• Decreased bowel sounds
• No gas or bowel movement
• How do you know drug is working?
• Bowel sounds heart in all four quadrants
• Client states has passes gas
• Client states has had a bowel movement

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Nursing Assessment Myasthenia Gravis

• Signs and symptoms muscle weakness, ptosis
  (droopy eye lid), diplopia (double vision),
  difficulty chewing and swallowing, decreased
  activity intolerance.
• How do you know medication is working? Increased
  muscle tone, no droopy eye lid or double vision,
  increased activity tolerance.

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Nursing Assessment Alzheimer

• Signs and symptoms loss of memory, cognitive
  function and decreased self-care
• Signs medication is working increase memory and
  cognitive function and increase interest in
  activities of daily living

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Use in Older Adults

• May be used in myasthenia gravis or Alzheimers
  disease

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Contraindications

• Renal obstruction
• Liver disease

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Anticholinergic Drugs

• Chapter 20
• Clinical Drug Therapy

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Anticholinergic Drugs

• Anticholinergics are a class of medications that
  inhibit parasympathetic nerve impulses by
  selectively blocking the binding of the
  neurotransmitter acetylcholine to its receptor in
  nerve cells.

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Mechanism of Action

• Drugs act by occupying receptor sites on target
  organs innervated by parasympathetic nervous
  system leaving fewer receptor sites free to
  respond to acetylcholine.
• Parasympathetic response is absent or decreased
  depending on number of receptors blocked.

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Effects of Anticholinergic Drugs

• CNS stimulation followed by depression
• Decreased cardiovascular response to
  parasympathetic (vagal) stimulation that slows
  heart rate
• Bronchodilation and decrease respiratory
  secretions
• Antispasmodic effects in GI system
• Change in intra-ocular pressure in patients with
  glaucoma

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Uses

• GI disorders peptic ulcer disease, gastritis,
  increased gastric acid secretion relax gastric
  smooth muscle (replaced by newer drugs)
• Genitourinary anti-spasmodic urgency
• Excessive secretions
• Ophthalmology relax eye for exam
• Respiratory disorder asthma or bronchitis
  inhaled form only
• Cardiac disorders bradycardia or heart block
• Parkinsons disease

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Side Effects

• Hyperthermia, hot, dry flushed skin, dry mouth,
  tachycardia, delirium, paralytic ileus and
  urinary retention

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Atropine

• Pharmacological classification anticholinergic
• Therapeutic classification antiarrhythmic
• Action Inhibits the action of acetylcholine at
  postganglionic sites located in the smooth
  muscle, secretory glands, CNS. Low doses
  decrease sweating, salivation and respiratory
  secretions.

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Atropine

• Therapeutic effects
• Increased heart rate
• Decreased GI and respiratory secretions
• Reversal of muscarinic effects
• May have spasmodic action on the biliary and
  genitourinary tracts.

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Atropine

• Side effects drowsiness, blurred vision,
  tachycardia, dry mouth, urinary hesitancy.

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Atropine

• Prototype of anticholineric drugs atropine
  sulfate
• Therapeutic
• Previously used in preoperative patients to
  reduce secretions other newer drugs have
  replaced