Drugs found on Mike's night table:
Diazepam (Valium) -> benzodiazepine
Diazepam, first marketed as Valium by Hoffmann-La Roche.
It is commonly used for treating anxiety, insomnia, seizures, muscle spasms, restless legs syndrome, alcohol withdrawal, benzodiazepine withdrawal, and Ménière's disease. It may also be used before certain medical procedures (such as endoscopies) to reduce tension and anxiety, and in some surgical procedures to induce amnesia.
Dosing:
Depending upon severity of symptoms: 2-10 mg, 2-4 times daily.
Adverse reactions:
Incontinence, changes in libido, urinary retention.
Somnolence, Suppression of REM sleep, Impaired motor function(Impaired coordination Impaired balance, Dizziness and nausea), Depression, Impaired learning, Anterograde amnesia (especially pronounced in higher doses), Cognitive deficits, Reflex tachycardia.
Tamsulosin (Flomax)
Tamsulosin is primarily used for benign prostatic hyperplasia, but is sometimes used for the passage of kidney stones by the same mechanism of smooth muscle relaxation via alpha antagonism.
Dosing: Flomax capsules 0.4 mg once daily is recommended as the dose for the treatment of the signs and symptoms of BPH. It should be administered approximately one-half hour following the same meal each day. For those patients who fail to respond to the 0.4 mg dose after two to four weeks of dosing, the dose of flomax capsules can be increased to 0.8 mg once daily.
Adverse effects:
Immunologic: It contains a sulfa moiety, thus causing typical reactions to sulfa drugs.
Ophthalmologic: Patients taking tamsulosin are prone to a complication known as floppy iris syndrome during cataract surgery. Adverse outcomes of the surgery are greatly reduced by the surgeon's prior knowledge of the patient's history with this drug, and thus having the option of alternative techniques.
Tamsulosin can cause males to experience retrograde ejaculation. Occasionally, tamsulosin can cause a drop in blood pressure, rarely resulting in dizziness or fainting. Other reported side effects include headache, dizziness, nasal congestion, and palpitations.
Lorazepam (Ativan) -> benzodiazepine
Lorazepam, initially marketed under the brand names Ativan and Temesta, is a benzodiazepine drug with short to medium duration of action. It has all five intrinsic benzodiazepine effects: anxiolytic, amnesic, sedative/hypnotic, anticonvulsant and muscle relaxant. It is a powerful anxiolytic, and, since its introduction in 1977, lorazepam's principal use has been in treating the symptom of anxiety. Among benzodiazepines, lorazepam has a relatively high addictive potential.
Dosing:
The dose of lorazepam is tailored to the patient's needs. The usual dose for treating anxiety is 2-3 mg/day given in two or three divided doses. Insomnia is treated with 2-4 mg given at bedtime.
Adverse effects:
Any of the five intrinsic benzodiazepine effects possessed by lorazepam (sedative/hypnotic, muscle relaxant, anxiolytic, amnesic and anticonvulsant) may be considered as "adverse effects" or "side-effects" if unwanted.
Paradoxical effects, Suicidality, Amnesic effects.
Temazepam (Restoril) -> benzodiazepine
Temazepam (marketed under brand names Normison, Temtabs, Euhypnos, Restoril, Remestan, Tenox and Norkotral) is an intermediate-acting 3-hydroxy benzodiazepine. It is generally prescribed for the short-term treatment of sleeplessness in patients who have difficulty maintaining sleep. Temazepam is not effective for induction of sleep. In addition, temazepam has anxiolytic (anti-anxiety), anticonvulsant, and skeletal muscle relaxant properties.
Dosing:
The recommended dose of temazepam when treating insomnia is typically 15 mg, taken at bedtime just before trying to go to sleep. For elderly people or people with other medical problems, the recommended dose is lower — 7.5 mg taken at bedtime.
Adverse effects:
Side effects typical of hypnotic benzodiazepines are related to CNS depression, and include somnolence, dizziness, fatigue, ataxia, headache, lethargy, impairment of memory and learning, increased reaction time and impairment of motor functions (including coordination problems), slurred speech, decreased physical performance, numbed emotions, reduced alertness, muscle weakness, blurred vision (in higher doses), and inattention.
Clonazepam (Klonopin) -> benzodiazepine
Clonazepam is a benzodiazepine derivative with highly potent anticonvulsant, muscle relaxant, and anxiolytic properties. It is marketed by Roche under the trade-names Klonopin in the United States, and Ravotril in Chile. Other names like Rivotril or Rivatril are known throughout the large majority of the rest of the world. Clonazepam is a chlorinated derivative of nitrazepam and a nitrobenzodiazepine like nitrazepam.
Dosing:
Clonazepam must be introduced gradually, and a low starting dose is advisable, such as 0.5 to 1.5 mg/day, which may be taken all at once or divided into two or three doses. The dosage can be increased by 0.5 to 1 mg every 3 to 7 days. The maximum daily dose recommended is 10 mg. In a survey of epilepsy specialists, most recommended no more than 4 mg per day and usually prescribed no more than 2 mg per day.
Adverse effects:
Common
* Drowsiness
* Impairment of cognition, judgment, or memory
* Irritability and aggression
* Psychomotor agitation
* Lack of motivation
* Loss of libido
* Impaired motor function
o Impaired coordination
o Impaired balance
o Dizziness
* Cognitive Impairments
o Increased Sleepwalking (If used in treatment of sleepwalking)
o Auditory Hallucinations
o Short-term memory loss
o Anterograde amnesia (common with higher doses)
* Some users report hangover-like symptoms of being drowsy, having a headache, being sluggish, and being irritable after waking up if the medication is taken before sleep. This is likely the result of the medication's long half-life, which continues to affect the user after waking up, as well as its disruption of the REM cycle.
Occasional
* Serious dysphoria
* Thrombocytopenia
* Serious psychological and psychiatric side-effects
* Induction of seizures or increased frequency of seizures
* Personality changes
* Behavioural disturbances
Rare
* Psychosis
* Incontinence
* Liver damage
* Paradoxical behavioural disinhibition (most frequently in children, the elderly, and in persons with developmental disabilities)
o Rage
o Excitement
o Impulsivity
Long term effects
The long term effects of clonazepam can include; depression, disinhibition and sexual dysfunction.
Trazodone (Desyrl)
Trazodone (Desyrel, Beneficat, Deprax, Desirel, Molipaxin, Thombran, Trazorel, Trialodine, Trittico) is a psychoactive drug of the piperazine and triazolopyridine chemical classes that has anti depressant anxiolytic, and hypnotic properties. It has been advertised that its therapeutic benefits become noticeable within the first week of administration. Trazodone has considerably less prominent anticholinergic (dry mouth, constipation, tachycardia) and sympatholytic (hypotension, sexual dysfunction consisting of erectile dysfunction and anorgasmia) side effects in comparison to most of the tricyclic antidepressants (TCAs) and tetracyclic antidepressants (TeCAs).
Dosing:
Treatment should be started with low initial doses of 25 to 50 mg daily in divided doses or in an evening single dose. The dose may be increased slowly to a maximum of 300 mg daily in ambulatory patients and to 600 mg daily in hospitalized patients. Geriatric and emaciated patients should begin with 25 mg daily; this dose may be slowly increased to 300 mg. The duration of treatment should be at least one month. A 50 mg dose is recommended when using Trazodone as a sleep aid.
Adverse effects:
The most common adverse reactions encountered are drowsiness, nausea/vomiting, headache and dry mouth. Adverse reactions reported include the following:
*Behavioral
Drowsiness, fatigue, lethargy, psychomotor retardation, lightheadedness, dizziness, difficulty in concentration, confusion, uncontrollable laughter, sex drive increase.
*Neurological
Tremor, headache, ataxia, migraine, akathisia, muscle stiffness, slurred speech, slowed speech, vertigo, tinnitus, tingling of extremities, paresthesia, weakness, complex partial seizures, and rarely, impaired speech, muscle twitching, numbness, dystonia, euphoria, and involuntary movements.
*Autonomic
Dry or numb mouth, blurred vision, priapism, diplopia, miosis, nasal congestion, constipation, sweating, urinary retention, increased urinary frequency and incontinence.
*Cardiovascular
Hypotension, tachycardia, palpitations, shortness of breath, apnea, syncope, arrhythmias, prolonged P-R interval, atrial fibrillation, bradycardia, ventricular ectopic activity (including ventricular tachycardia), myocardial infarction, and cardiac arrest.
Tizanidine (Zanaflex)
Tizanidine (brandnames Zanaflex, Sirdalud) is a drug that is used as a muscle relaxant. It is a centrally acting a-2 adrenergic agonist. It is used to treat the spasms, cramping, and tightness of muscles caused by medical problems such as multiple sclerosis, spastic diplegia, back pain, or certain other injuries to the spine or central nervous system. It is also prescribed off-label for migraine headaches, as a sleep aid, and as an anticonvulsant. It is also prescribed for some symptoms of fibromyalgia.
Dosing:
To minimize side effects, begin with a dosage of 4 milligrams, then increase the dose gradually. Doses of 8 milligrams provide relief for most people. No more than 3 doses should be taken each 24 hours. The maximum dose per day is 36 milligrams.
Adverse effects:
Tizanidine use occasionally causes drug induced liver injury. In controlled clinical studies, approximately 5% of patients treated with Zanaflex had elevations of liver function tests (ALT, AST) to greater than 3 times the upper limit of normal (or 2 times if baseline levels were elevated). Do not use tizanidine at a time when muscle tone is needed to assure safe balance and movement for certain activities.
Administered on June 25th:
01.30: 10mg tablet of Valium.
Diazepam, first marketed as Valium by Hoffmann-La Roche.
It is commonly used for treating anxiety, insomnia, seizures, muscle spasms, restless legs syndrome, alcohol withdrawal, benzodiazepine withdrawal, and Ménière's disease. It may also be used before certain medical procedures (such as endoscopies) to reduce tension and anxiety, and in some surgical procedures to induce amnesia.
Dosing:
Depending upon severity of symptoms: 2-10 mg, 2-4 times daily.
Adverse reactions:
Incontinence, changes in libido, urinary retention.
Somnolence, Suppression of REM sleep, Impaired motor function(Impaired coordination Impaired balance, Dizziness and nausea), Depression, Impaired learning, Anterograde amnesia (especially pronounced in higher doses), Cognitive deficits, Reflex tachycardia.
02.00: 2mg Lorazepam (Ativan) after dilution, into IV.
Lorazepam, initially marketed under the brand names Ativan and Temesta, is a benzodiazepine drug with short to medium duration of action. It has all five intrinsic benzodiazepine effects: anxiolytic, amnesic, sedative/hypnotic, anticonvulsant and muscle relaxant. It is a powerful anxiolytic, and, since its introduction in 1977, lorazepam's principal use has been in treating the symptom of anxiety. Among benzodiazepines, lorazepam has a relatively high addictive potential.
Dosing:
The dose of lorazepam is tailored to the patient's needs. The usual dose for treating anxiety is 2-3 mg/day given in two or three divided doses. Insomnia is treated with 2-4 mg given at bedtime.
Adverse effects:
Any of the five intrinsic benzodiazepine effects possessed by lorazepam (sedative/hypnotic, muscle relaxant, anxiolytic, amnesic and anticonvulsant) may be considered as "adverse effects"; or "side-effects" if unwanted.
Paradoxical effects, Suicidality, Amnesic effects.
03.00: 2 mg Midazolam (Veresed) after dilution, into IV.
Midazolam, marketed in English-speaking countries under brand names Dormicum, Hypnovel, Midacum and Versed) is an ultra short-acting benzodiazepine derivative. It has potent anxiolytic, amnestic, hypnotic, anticonvulsant, skeletal muscle relaxant, and sedative properties. Midazolam is water-soluble and fat-soluble in physiologic pH. Freely soluble in alcohol and acetone. It is considered an ultra short-acting benzodiazepine, with an elimination half-life of about 2 hours. It is used in some countries for the short term treatment of insomnia and in many countries as a premedication before surgery. It is therefore a very useful drug to use for short minor procedures such as dental extraction.
Dosing:
Initial dose: 1-2 mg
Additional doses: 1 mg administered at 2-minute intervals
Onset of action: 1-2 minutes
Peak effect: 3-4 minutes
Duration of effect: 15-80 minutes
Adverse effects:
Residual 'hangover' effects after nighttime administration of midazolam such as sleepiness, impaired psychomotor and cognitive functions may persist into the next day which may impair the ability of users to drive safely and increase risks of falls and hip fractures. Confusion and amnesia are reported with midazolam. Midazolam has been known to cause a paradoxical reaction in susceptible individuals, a well-documented complication with benzodiazapines. When this occurs, the individual may experience anxiety, involuntary movements, aggressive or violent behavior, uncontrollable crying or verbalization, and other similar effects. This seems to be related to the altered state of consciousness or disinhibition produced by the drug. Some patients may respond to as little as 1 mg. No more than 1.5 mg should be given over a period of no less than 2 minutes.
05.00: 2 mg Lorazepam (Ativan), after dilution, into IV. See above.
07.30: 2mg of Midazolam (Versed), after dilution, into IV. See above.
10.40: 25 mg of Propofol (Diprivan), diluted with Lidocaine (Xylocaine), via IV drip.
Propofol (INN, marketed as Diprivan by AstraZeneca) is a short-acting, intravenously administered hypnotic agent. Its uses include the induction and maintenance of general anesthesia, sedation for mechanically ventilated adults, and procedural sedation. Propofol is also commonly used in veterinary medicine. Propofol is approved for use in more than 50 countries, and generic versions are available.
Chemically, propofol is unrelated to barbiturates, and has largely replaced sodium thiopental (Pentothal) for induction of anesthesia as recovery from propofol is more rapid and "clear" as compared to thiopental. Propofol is not considered an analgesic, so opioids such as fentanyl may be combined with propofol to alleviate pain.[1] Due to its amnestic effects and appearance as a white liquid, propofol has been humorously dubbed "milk of amnesia" by medical professionals.
Dosing:
Anesthesia induction, [healthy adults
Dose: 2-2.5 mg/kg IV given as 40 mg q10sec until induction onset
Anesthesia maintenance, [healthy adults
Dose: 0.1-0.2 mg/kg/min IV; Alt: 25-50 mg IV prn
Monitored anesthesia care induction
[100-150 mcg/kg/min IV x3-5min]
Alt: 50 mcg/kg IV x1 over 3-5min, then maint. Infusion
Monitored anesthesia care maintenance
[25-75 mcg/kg/min IV]
Alt: 10-20 mg IV prn; Info: avoid bolus doses and reduce dose 20% in elderly, debilitated, neurosurgical, or ASA P3-P4 pts
Adverse effects:
Aside from low blood pressure (mainly through vasodilation) and transient apnea following induction doses, one of propofol's most frequent side effects is pain on injection, especially in smaller veins. This pain can be mitigated by pretreatment with lidocaine. Patients show great variability in their response to propofol, at times showing profound sedation with small doses. A more serious but rare side effect is dystonia. Mild myoclonic movements are common, as with other intravenous hypnotic agents. Propofol appears to be safe for use in porphyria, and has not been known to trigger malignant hyperpyrexia.
It has been reported that the euphoria caused by propofol is unlike other sedation agents,"I even remember my first experience using propofol: a young woman who was emerging from a MAC anesthesia looked at me as though I were a masked Brad Pitt and told me that she felt simply wonderful" —C.F. Ward, M.D.
Propofol has reportedly induced priapism in some individuals.
After Mike stopped breathing:
0.2 mg of Flumanezil (Anexate) was administered once.
Flumazenil (Anexate), in affidavid listed as Flumanezil 
Flumazenil, a specific benzodiazepine-receptor antagonist, is indicated for the complete or partial reversal of the sedative effects of benzodiazepines and may be used in situations when an overdose with a benzodiazepine is known or suspected. Prior to the administration of flumazenil, necessary measures should be instituted to secure airway, ventilation and intravenous access. Flumazenil is intended as an adjunt to, not as a substitute for, proper management of benzodiazepine overdose. Patients treated with flumazenil should be monitored to resedation, respiratory depression and other residual benzodiazepine effects for an appropriate period after treatment. The prescriber should be aware of a risk of seizure in association with flumazenil treatment, particularly in long-term benzodiazepine users and in cyclic antidepressant overdose.
Dosing:
The recommended dose for adults is 0,2ml every 1–2 minutes until the effect is seen, to a maximum of 3 mg per hour. The onset of action is rapid and usually effects are seen within one to two minutes. The peak effect is seen at six to ten minutes.
Drugs found via autopsy:
Propofol (see above)
Lorazepam (see above)
Midazolam (see above)
Diazepam (see above)
Lidocaine
Lidocaine (INN) or lignocaine (former BAN) is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic, and in minor surgery.
Dosing:
Unknown, in this case Propofol was diluted with Lidocaine.
Adverse effects:
Systemic exposure to excessive quantities of lidocaine mainly result in central nervous system (CNS) and cardiovascular effects – CNS effects usually occur at lower blood plasma concentrations and additional cardiovascular effects present at higher concentrations, though cardiovascular collapse may also occur with low concentrations. CNS effects may include CNS excitation (nervousness, tingling around the mouth (also known as circumoral paraesthesia), tinnitus, tremor, dizziness, blurred vision, seizures) followed by depression, and with increasingly heavier exposure: drowsiness, loss of consciousness, respiratory depression and apnoea). Cardiovascular effects include hypotension, bradycardia, arrhythmias, and/or cardiac arrest – some of which may be due to hypoxemia secondary to respiratory depression.
Ephedrine
Ephedrine is a central nervous system stimulant used to treat breathing problems (as a bronchodilator), nasal congestion (as a decongestant), low blood pressure problems (orthostatic hypotension), or myasthenia gravis. Ephedrine stimulates fatburning and increases alertness and activity of the body. Ephedrine increases the energy and concentration for 6 to 10 hours. The energy released will inhibited the appetite. Ephedrine can also be used for asthma, hay fever and colds.
Dosing:
For prescription ephedrine, do not exceed 150 mg per day in adults.
Adverse effects:
Adverse drug reactions (ADRs) are more common with systemic administration (e.g. injection or oral administration) compared to topical administration (e.g. nasal instillations). ADRs associated with ephedrine therapy include:
Cardiovascular: tachycardia, cardiac arrhythmias, angina pectoris, vasoconstriction with hypertension
Dermatological: flushing, sweating, acne vulgaris
Gastrointestinal: anorexia, nausea
Genitourinary: diuresis (increased urination) due to increased blood flow (difficulty urinating is not uncommon, as alpha-agonists such as ephedrine constrict the internal urethral sphincter, mimicking the effects of sympathetic nervous system stimulation)
Nervous system: restlessness, confusion, insomnia, mild euphoria, mania/hallucinations (rare except in previously existing psychiatric conditions), delusions, formication (may be possible, but lacks documented evidence) paranoia, hostility, panic, agitation
Respiratory: dyspnea, pulmonary edema
Miscellaneous: dizziness, headache, tremor, hyperglycemic reactions
The approved maximum daily dosage of ephedrine for use as a bronchodilator is 150 mg, as specified on the packaging of the bronchodilator and expectorant combination, Bronkaid, made by Bayer pharmaceuticals.
Overdose can lead to death, although the approved dose is not likely to cause severe reactions when used as directed.
